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198 What Goes into Building an AI Company in the IVF Space Featuring Paxton Maeder-York

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Whether you’re a fertility doctor looking to make an AI company or a tech entrepreneur entering the fertility field, this week’s episode of Inside Reproductive Health is full of interesting insights.

Paxton Maeder-York. CEO and Founder of Alife Health, breaks down how he started his medical AI company, and walks you through the business and regulatory obstacles required to stay in business.

Tune in to hear Paxton discuss:

  • How an AI company is funded and founded (And If it’s possible to bootstrap without outside investment capital)

  • The unbiased large heterogeneous datasets required to run AI (Not to mention the other companies needed to acquire this data)

  • How he chose his early investors and advisory board (Including former guest Dr. Michael Levy)

  • The monumental difference in data science between 85% good and 99.99%

  • Navigating the high regulatory burdens within the Healthcare Space

  • The criteria for when it’s appropriate for a VC funded company to acquire other companies.


Paxton Maeder-York:
LinkedIn
Alife Health

Transcript

Paxton Maeder-York  00:00

Data sciences, you know, it's not that hard to get to an initial assessment or to, you know, the 85% mark, but that last 10 to 15% of performance is all the difference in the world between, you know, you know, making something that is reliable and safe for patients that's unbiased, and making something that's really more of a, you know, a school project. And I think, I think that's a huge delta that we're gonna continue to see. And I don't just mean within IVF or even healthcare broadly, I think that's a problem that we're gonna see across AI as this whole sector continues to grow. We see it in enterprise we see it self driving cars, we see it everywhere. And so, you know, I think when you're talking about getting to that, you know, 99% or .99 following you know, it requires a really talented team and investment and thoughtful you know, methodical development, and that that does require a capital upfront.

Sponsor  00:55

This episode was brought to you by Embie. To see where your time is going visit embieclinic.com/report. That's embieclinic.com/report. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode, and the guests appearance is not an endorsement of the advertiser.

Griffin Jones  01:33

Building an AI company in the fertility space, many of you have business backgrounds, many of you have medical backgrounds. What about bio mechanical engineering? What about surgical robotics? What about data science? Today, my guest is CEO Paxton Meader-York, I don't delve much into his company a life for what they do for the fertility field. Instead, I tried to give you an idea about how an AI company is funded, founded and managed from the start. We start with Paxton leaving Harvard with a degree in Biomechanical Engineering cutting his teeth in the Silicon Valley ecosystem working in surgical robotics going back to Cambridge getting his data science master's and his MBA back to Silicon Valley, how he chose some of the people on his advisory board and early investors including Dr. Michael Levy of Shady Grove and Dr. Allen Copperman of RMA of New York packs and talks about the investors that led their Series A round and their seed round. I asked Paxton if it's even possible to build an AI company bootstrapped no investment. He talks about those barriers, including the unbiased large, heterogeneous datasets that are required, and consequently, the companies that are usually required to partner with to get those datasets. He talks about the high regulatory burden, especially in healthcare, and the monumental difference in data science between 85% good and 99.99%. I tried to get criteria from Paxton why they haven't acquired a company yet, because I'm trying to get criteria for you of when it's too early for new VC funded companies to go off acquiring other companies. Finally, I get Paxton to talk a little bit about their tech stack, their org structure and their team, software product and so on. If you're a fertility doctor looking to build an AI company or a tech entrepreneur entering the fertility field, I hope you enjoy this founder story with Paxton Meader-York. Mr. Meader-York, Paxton, welcome to the Inside Reproductive Health podcast.

Paxton Maeder-York  03:18

Thank you so much for having me, Griffin, it's great to see you.

Griffin Jones  03:21

I look forward to talking with you. I've had a couple founders on recently, Dr. Brian Levine was one of them and that was a very popular episode. Got to go into the mechanics of how he started his company, I want to go into the mechanics of how you started your company. And I want to, there might be some things, likfe funding and structure that in some of the circles you run with might be elementary, but not as elementary to some of the people that want to start companies in the fertility field. And so let's maybe just start with how your company started. We can we can talk about the idea and the genesis, and then I'll really want to get into the mechanics.

Paxton Maeder-York  04:03

Absolutely. And thank you again for having me on. It's really great to be here. So yeah, I'll start with maybe a little bit of background about myself. So I've been passionate and in really engaged with medical technology for a long time now really started for me back in middle school where I was watching surgeries at MGH and doing robotics camps at MIT. I ended up studying biomedical engineering at Harvard undergrad, really focusing in surgical robotics, and then working at a company called Oris health out in the Bay Area that was focused on lung cancer systems. So I had lost several grandparents to lung cancer. It was a really important mission to me, and really got to cut my teeth in the Silicon Valley startup ecosystem. When that company got acquired by Johnson and Johnson, I went back and did a master's in data science as well as my MBA back at Harvard, and really became passionate around the opportunities for artificial intelligence and advanced analytics, more broadly across health care. My little brother's actually an IVF baby. And so infertility care has always been something that's been incredibly important to me both personally, and as we see the growing trends across the population, it's only of increasing importance to many folks. And so started the company about three years ago really with the mission of trying to bring modern data science techniques and personalized medicine to the forefront of the IVF sector.

Griffin Jones  05:29

So you're at Harvard for undergrad, and that's where you got your degree in surgical robotics?

Paxton Maeder-York  05:34

Yeah, so biomedical engineering undergrad, and then grad school was both masters and data science and then an MBA.

Griffin Jones  05:40

Okay, so biomedical engineering, and then that's what brought you out to Silicon Valley. And I'm sorry, you may have said it, and I may have missed it, were you the the founder of that company that you went to work for in Silicon Valley, or you're working for somebody else at that time?

Paxton Maeder-York  05:54

I was working for somebody else, and really was hoping to learn a lot from a very experienced CEO, Fred Moll, who founded that company actually founded Intuitive Surgical, which is the preeminent preeminent system out there in the robotic surgery space really pioneered the sector. And so you know, learned a ton from working with him and the other amazing folks there, actually, a couple of those I worked with at Oris came over and are now running a lot of the A Life team. So certainly was was an incredible experience for me early on in my career.

Griffin Jones  06:26

So you could have stayed and then worked for a different Fred, and a couple of Fred's and stead of going back to the east coast to get your advanced degree at Harvard. Why, why go back? Why go for the advanced degree as opposed to staying in the Silicon Valley ecosystem that you cut your teeth in?

Paxton Maeder-York  06:48

So you know, I think there are a variety of reasons for it. You know, my, my undergraduate focus was really in bio mechanical engineering, so medical device. And, you know, I got to learn a lot about the complexity of bringing robotic systems and complex medical devices to market, both from a development standpoint and a commercialization standpoint. But I've always been fascinated around data science, and really, its propensity to answer big questions, right? Whenever we think about asking a question whether, you know, it's in politics, or healthcare or any other sector, right, I think, you know, everybody turns to Google and looks at, you know, large scale studies, and really everyone's, you know, looking for data to answer that question. And so becoming more proficient at data analytics, understanding how to use modern data science, especially reinforced with the incredible computational power we have at our fingertips today was just an area I was super passionate about. And on top of that, you know, I always known I wanted to be a leader and hopefully found a company someday. And so by working and getting my MBA as well, it gave me a lot of context on the broader economy, how companies scale, and also hopefully, will allow us to continue to grow into the long term vision that we set out for at Alife. 

Griffin Jones  08:10

But what was it about either Harvard at that time, or the degree itself where you felt like you would get that leadership background more through an MBA and more of the data science understanding from an advanced degree as opposed to working for a couple other biomed startups or a few other, even maybe even more mature companies, out there in the in the tech sector? 

Paxton Maeder-York  08:38

Yeah. So I mean, I think it's a couple of things. I mean, one as an engineer, and I really consider myself as an engineer, first and foremost, you know, I always want to understand as much as I can about the technology before going out and, and building it either with a team or on my own. And so I certainly felt like the the advanced mathematics I was taking in my master's program, and also just really diving in and understanding how this recent kind of trend of artificial intelligence, I know it's a topic that has been talked about since the 80s, if not earlier, but a lot of the really exciting work that's happening in AI is really started in 2017, with a lot of the image based pattern recognition work, AlexNet, and so forth. And and then on top of that, on the MBA side, you know, I worked at Oris, got an incredible kind of mini degree from from that experience, I did spend a summer working with Google X. So got, got to scratch the itch and see what was going on inside of that black box. But with the MBA really gave me was the opportunity to look at hundreds of different businesses and all these different contexts and that type of pattern recognition similar to what we deploy on the actual medical technology side, you know, I think is really valuable as a young person as a leader and as someone who's continuing to try to strive to scale businesses and of course, deliver huge value to both clinicians and patients in the long run.

Griffin Jones  10:02

So I don't think this is degressing too much, I think this might be at the crux of why you went back versus why one might not go back to get that more advanced education. And I think of, there's a common adage that says, You don't have to be the expert in a given field. And they'll they'll cite Henry Ford, and they'll say, you know, Henry Ford was not a mechanical engineer, he didn't build cars himself, he, but yeah, but he knew a ton about cars. And, and I just don't believe that you can't have a certain ground level of understanding in a subject and then build a business out no matter how good you are as a, as a manager of people, as a capitalist in raising money, that you have to have some type of, you have to have some type of background. And for you building a tech company, I think what is, what would you consider the minimum level of background to know that you're not being fleeced? Or that you can, even if you're not being worried about being fleeced by people that work for you, that you can sufficiently instruct to them and delegate to outcome? So what do you think the basement is for that? Or where have you found yourself using your degree or to be able to, to use it to for the vision of the company?

Paxton Maeder-York  11:31

Well, I certainly wouldn't say that these types of degrees are required for anyone trying to start a business. And of course, a lot of the people listening to this podcast, you know, are extremely, you know, proficient, either in their field, a lot of people have PhDs or MDs, I think, you know, it's, it's a tough couple of different components. You know, one, obviously, the nature of the business, I think, is important, right. And, you know, if if there are many companies out there, where the founder may be technical, or may have a purely sales background, and those types of leaders can can bring enormous value to the organization, I think a lot of it does have to do with kind of the mindset of the leadership and how well you're able to accumulate a team of experts in those different domains and fit the pieces to the puzzle together. You know, having said that, I think if you're going out and trying to do something extremely technical, and also something that has, you know, pretty substantial ramifications for your end customer base like we do, in infertility. You know, I think at that point, it's, it's always valuable to have a technical proficiency in that type of technology. And so, you know, it was it was my approach, and it may not have necessarily been the one that is required for everyone. But I certainly wanted to have as much know how in medical technology development and all the regulation and quality management system and you know, kind of the domain level expertise in that having done that in the surgical robotics space, and then combine that with technical know how around data science so that we can look at these problems, and I can contribute, and also, hopefully recruit an incredible team of data scientists and AI experts to this specific application. Which, personally, I think is an incredible application of this type of technology. I think there's so much opportunity for advanced analytics across healthcare, but specifically, within IVF. Just to help support bringing personalized medicine and helping clinicians deliver the best care they possibly can, whether that's digitalising, the embryology workflow, helping to capture image and images and, you know, kind of manage, manage expectations on that side or, you know, helping to select the optimal ovarian stimulation protocol and when to trigger, which is another component of what we build at Alife. So, you know, I think the the short of it is, there is no basement, if that, if that makes sense. But I think, you know, certainly in this arena, I wanted to feel as prepared as humanly possible before I strove out and tried to build the company on my own to go and tackle some of these problems.

Griffin Jones  14:00

And did you strive out right after you got your MBA and your masters in data science? Or did you go back work for somebody else? And then that came later?

Paxton Maeder-York  14:11

No, I strove out right after my graduation. So actually, the application of using AI and computer vision on embryo analysis was kind of a the initial project and something I worked on as my master's capstone thesis. And then that spun out into the company. And then of course, you know, when you start a company, one of the great pieces of advice I got early on in my career from a close advisor was, as soon as you kind of have the pieces in the toolbox that you need, and you have an idea, you go off and do it and you start pulling on the thread. And of course, as you pull on the thread, and you start working on the problem, and you work with customers, and you learn more about the space and you build an advisory board and you ask what types of problems clinicians or patients are seeing, you learn more and more. And so when you look at the genesis of Alife and how much we're doing today relative to the initial idea, a lot of that has expanded over the last three years, and transparently a lot of those amazing technologies or product ideas didn't come from me. The holistic vision came from me of we're going to head in this direction and built incredible products and use AI to help support people who want to start, continue, or finalize their families, but great ideas come from anywhere. And that's really where, you know, bringing an amazing group of people together and working collaboratively, I think personally results in the in the best outcomes.

Griffin Jones  15:35

So you start working on it, at what point did you build the advisory board? Did you build your advisory board before you started raising money?

Paxton Maeder-York  15:41

I did. So you know, when I first started out, I kind of had this idea, I started talking to a few investors and immediately started talking to many different, you know, top doctors in the space, either through you know, connections or cold emails, there's a whole component of this, that is just straight hustle. And you know, over time you build rapport. And you know, some of the incredible folks, Michael Levy, for example, at Shady Grove, now US Fertility, was one of the first folks that I was lucky enough to get to work with. And then as you know, you kind of continue to build reputation in this space, more and more people and top clinicians got excited by both our team, how we were approaching the problem, how we worked on these types of issues together and integrated our clinical advisors feedback. And so our clinical advisory board just has continued to grow. And the whole team, which is now you know, over 28 folks strong, is constantly looking for feedback testing, working with those doc's to run studies to validate our algorithms. It's kind of a constant approach. And so I think that advisory board has been an incredible asset for the company, and we're super grateful to have all of their support.

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Griffin Jones  18:03

How do you manage the interests of different people either on the advisory board or some of those earlier folks that you're working on the problem and consequently the product with, so Michael Levy at Shady Grove is a very big center and group of centers. And as big as Shady Grove and US Fertility are they're not the entirety of the market. And any startup faces a challenge where they can they can fall into scope and create too much. So how did you how did you balance that, especially with that particular this is a really big center, you could build something that's just for them and assume that it's applicable to everyone. But there's a wide variance in workflows of clinics of all kinds. So how did you balance the needs of maybe this one, two, three, four people that we're working with now in this moment versus what's really going to be scalable for a business going forward?

Paxton Maeder-York  19:05

It's difficult. And I think, you know, this is a pitfall that a lot of people, you know, fall into right is how do you avoid just building a tailored solution to a single customer? And you know, while Dr. Levy was, you know, one of the first people I spoke to just through a connection right at the beginning of the company before I even raised. Very quickly, we built out a much larger advisory board, Alan Copperman from RMA New York who has been really involved with our story, a number of others. And then there's there's just a really thorough playbook that you follow of having a lot of discovery conversations, you know, going to clinics, seeing how they operate, finding those different you know, kind of similarities and differences. And you kind of look for the overlap in the venn diagram where this is a consistent problem across practices. This is something that the technology can you know meaningfully make an impact on. And it is different, you know, a lot of companies in the medical technology space, you know, pick one chief medical officer, for example, and bring them on. And a lot of the product development is done in relation to that individual. And one of the things I've learned in surgical robotics is exactly what you're pointing to, which is that different folks, different clinicians have very different perspectives on you know, what's important to look at. And, as you said, different clinics operate differently. And so, you know, we kind of went with this more broad approach of instead of having a single voice, let's get as many as we can have the top folks in the space, and that is, you know, both, you know, horizontally and laterally across clinics and vertically within those clinics. So, talking to frontline, you know, embryologist, junior embryologist, talking to clinic admin staff, talking to nurses, you know, talking to lab directors, it's really the entire encompassing of the field. And of course, we've interviewed hundreds and hundreds of patients at this point, as we've built free patient products, and also worked to figure out how we're going to bring value with the AI solutions that are going into the clinic. So it's, it's not really a crowdsource model, but it's almost kind of like that. And then, you know, in terms of how to how to really solidify what you're building, I credit our incredible product team, and especially Melissa Teron, who's our chief operating officer, for doing a lot in that that area, there are certainly playbooks you can follow and best practices and you know, modern product development and things like IDEO, you know, really paved the way for some of those things. And the Stanford design school has got a lot of incredible resources. But, you know, it's definitely an art that in terms of figuring out where the opportunity is, and how do you shape the technology to best fill that need. 

Griffin Jones  21:50

When you are getting your MBA, where there are different schools of thought about how you should approach fundraising, that you should phase it in this order, or you should try to get more in in an earlier phase or a later phase, or where there are different schools of thought, and how did you pick the approach that you ended up going with?

Paxton Maeder-York  22:09

You know, there's not only different schools of thought, within, you know, business schools, there's different schools of thought within the venture community. And then there's different schools of thought founder to founder. And that was something that I learned over the course of, you know, the first year and a half or so. And I'm lucky in that I have a number of friends who have also started companies at various stages. But what you learn pretty quickly is that the approaches that other people take around fundraising may or may not necessarily work for you. Now, there are obviously a variety of different types of capital sources out there, you can bootstrap a startup, you can look to private equity, or traditional LBO, you can do entrepreneurship through acquisition, you know, and then there's more of the traditional venture route, which is the route that Silicon Valley is known for, and the route that Alife has taken. But I think what's what's interesting is that, you know, fundraising and figuring out who the right partners are, for the long term, because as you know, as soon as you bring on an investor, and they've put significant amounts of money behind your vision, you're going to be working with them for a long time, they are invested in your story. I got really lucky that I found Deena Shakir, who lead our seed, and lead our Series A and she's been one of our number one advocates for the business since day one. She's been absolutely incredible, through and through. But I think that it's there's so much that goes into fundraising that is beyond just kind of the hype and the FOMO, and pitching. A lot of it in my perspective is about finding that right fit. And who is someone that is going to work with you in the long run? Very similar, I would, I would argue to creating a leadership team. I think a lot about my board the same as I do, developing my internal leaders and how different skill sets are gonna complement each other. So I think every founder is a little different about how they approach that problem. But for me, you know, it was it was a lot of conversations. And I was very fortunate to find some incredible folks, Rebecca Kaden at Union Square Ventures is another one who came on at Series A who just, you know, clearly understands and is passionate about the long term vision of the company. And, you know, I think it's really important to find those folks as early on as you can when you're going out and building something important.

Griffin Jones  24:23

What was it about Deena and Rebecca that made them a good fit?

Paxton Maeder-York  24:27

You know, there's, there's certainly, you know, kind of the more traditional, you know, filters that you can apply, right? Coming from great firms, you know, very sharp investors, certainly asking great questions, bring resources to the table, not just capital but also in terms of advice and network and, you know, you know, other kind of intangible assets. But I think you know, even more so than that, it really is almost a personal decision too. Who do you think are going to be a great fit for your company, the culture you're trying to build? Who, you know, is going to be the right fit for you as a founder? And who, you know, who you want to work with and you know, are ultimately going to be able to, A, keep you accountable, but B, when you need support from the board level or from your investors, or we're going to represent you either in the media or to, you know, follow on investors in later rounds, it is, they say that VC and raising capital is a lot like dating. And I certainly think that that's true. It's, it's, it's, you know, there's things on paper that make it important. And then there's kind of an intangible personality fit that I think is so crucial to get right when you're out fundraising.

Griffin Jones  25:36

Did you have relationships with either or both of them before you went to raise money? Did you meet them during the process?

Paxton Maeder-York  25:43

So I really met both of them during the process. So Deena works at Lux capital, which is an incredible firm, and probably the best deep tech investor VC that I know of, and they had invested in Oris, the company I worked at after undergrad. I had not met Deena during that experience. But you know, when I started Alife and was starting to tiptoe around the capital side of the business, Peter Hébert, one of the founders of Lux, put me in touch with Deena and Peter's a genius, and could tell that Deena and I were going to be a great fit. And then Deena and I spent months and months getting to know each other before, you know, we kind of solidified the relationship culminating in our seed round. And, you know, I really cherish that time. I think it was so valuable that Deena and I got to spend so much time together up front, it's deepened our partnership. And, you know, I think it's, it's ultimately, you know, I consider her you know, as a co founder of the business in a lot of ways. And then Rebecca Anaergia who is from Mavron, who's also incredible, I really got to know a lot closer during the Series A round. And that was a faster kind of, you know, relationship building period, of course, we're continuing to get to know each other and work closely together, every, you know, you know, board meeting and in between and our monthly calls and working through, you know, challenges and exciting milestones for the company, it's constant. But I think similarly, there's, there's just kind of a great fit personality wise, and also in terms of their passion for this space.

Griffin Jones  27:15

I just had Kim Abernethy, from PCA interview me for my own show over Inside Reproductive Health. I don't know if that episode will come out before or after this interview airs. But as I was searching for the central theme of what that conversation ended up being I ended up titling the episode Should Fertility Companies Stop Taking Outside Funding, and then making a categorical assertion that they should stop taking outside money. It was more a call to attention to, for many companies, to invest more in the product market fit phase. That it takes a long time to do that, I see a lot of people burning out money before that's established. And then and then it's really hard. And I think more people could do some bootstrapping, and we might see it as the economy changes over the coming years. I do not say that that's a categorical prescription for everyone. And I know that there's a lot of limit to doing that in tech, especially with AI. Do you think it's even feasible to bootstrap in AI? Now that you're in now that, you've seen the money that you spent, the people that you've hired, the things that you've built? Is it possible to build it to bootstrap and an AI company in the biomedical space? And if it's not, is it possible up to even a certain phase?

Paxton Maeder-York  28:36

You know, it's a great question. I think, to a certain extent, I would hate to say something is impossible, right. And I would love to see someone go out and do it in a purely bootstrapped fashion, I think there are a few things that come to mind that make it very difficult. First off, artificial intelligence really requires an unbiased and very large and heterogeneous data set, that takes a lot of time to develop. And you typically need some sort of relationship or partnership to be able to, to gather that data, and a lot of folks rightly so right, this is really valuable data, you know, want to partner with a reputable company that has all the right data privacy and experts and PhDs that are, you know, it's an investment in both directions. So I think that's one component of it that would make it challenging. I also think that anytime you're doing things in medicine or medical device, there's a high regulatory burden. There are clinical trials and clinical studies that you have to publish. There's quality management systems and making sure that you're you know, following all the all the metrics so that it is medical grade software, and that requires a lot of investment. So you know, I think to do it right, I think it does require a really expert team and it takes a certain amount of time to get a product to the to MVP where you could go out and actually charge either you know, a clinic or you know, a patient or whoever might be your customer across healthcare. That isn't to say it couldn't be done. I think that there are other approaches that one could take to building artificial intelligence, especially if you already had access to a significant amount of data through different types of partnerships or relationships. But, you know, I think, while software is still a lot less capital intensive than robotics was and hardware, obviously, you have to build manufacturing, and, and all the rest, you know, I think it still does require a lot of capital to get these types of technologies off the ground. And more importantly, to do them, right. You know, and I think that's, that's where a lot gets lost data sciences, you know, it's, it's not that hard to get to an initial assessment or to, you know, the 85% mark, but that last 10 to 15% of performance is all the difference in the world between, you know, you know, making something that is reliable and safe for patients that's unbiased, and making something that's really more of a, you know, a school project. And I think, I think that's a huge delta that we're going to continue to see. And I don't just mean, within IVF, or even healthcare broadly, I think that's a problem that we're gonna see across AI, as this whole sector continues to grow. We see it in enterprise, we see it self driving cars, we see it everywhere. And so, you know, I think when you're talking about getting to that, you know, 99%, or point nine, nine, following, you know, it requires a really talented team and investment and thoughtful, you know, methodical development, and that that does require capital upfront.

Griffin Jones  31:31

So there are certain verticals where the barrier to entry is simply too expensive. There's high regulatory burden, there's a number of things that partners might need if they're going to help get a burgeoning company to the MVP phase, then how do you make sure that you don't burn through all of your dough while you're assessing product market fit? Because I see lots of companies that say, Man, you don't have it, like you just raised X million dollars, and you don't have anything that people are going to buy right here. You had, like, you saw the problem, the problem was there, I don't think any more studies would have more clearly revealed the problem or even talking to more customer necessarily would have revealed the problem, they got that part. They, they had some type of solution to bring to the marketplace. And it just didn't fit together, like a lot of these these companies that that don't make it or or maybe make it a little bit never returned the type of profit that they would be projected to do so for what they were valued at. How do you keep yourself from spending through too much money while you're assessing product market fit? 

Paxton Maeder-York  32:56

Well, it's a it's a philosophical debate, honestly, you know. I think there are tons of books out there that have discussed this exact problem, you know, Crossing the Chasm, and, you know, the proverbial valley of death. Of course, I think, you know, it's a few things, I think, one, there is a certain amount of discipline that's required, right. And, you know, we have a very strong, talented, but lean team, that is very intentional, you know, we were always trying to make sure that our burn as a company is on track with the development and making sure that we're validating what we've built, both from a clinical and science perspective, but also from a product market fit perspective. I'd also say that, you know, getting to MVP, this, the proverbial product market fit is is challenging and, you know, you kind of going back to my analogy earlier of pulling on the string, you know, you you may have one hypothesis about what a product might look like, that's going to bring significant amount of value, you may test that out, you may realize that's not where there's an enormous amount of value, and that there's additional capability you need to bake in so that it's a compelling sale on a compelling use case for the end customer. And that is to some level and art, I would say come over time. But I think in general, you know, I think folks that have worked in different types of industries and try to come to healthcare, I think, typically will struggle with this. It is healthcare, in general is a much slower moving market than traditional consumer or enterprise SAS. I think, you know, it requires wherewithal and long term thinking and a methodical march towards product introduction, and, and ultimately, you know, you know, getting the system out there so that it can benefit both clinicians and patients alike. And, you know, I think we saw that and in a variety of different stories. It's something that I certainly experienced firsthand when I was working on robotic surgery and that was an incredible success story at Oris. But it's just kind of the nature of the beast. And so, you know, I think making sure that what you're trying to build and In that you're constantly innovating, expanding the vision, making sure that you're adding functionality that is continuing to add and drive more value creation for your end users is just a constant process that we expect to be doing in perpetuity, along with all the incredible research that we're doing with our advisors and our clinical partners and other folks. And so as long as you, I think, plan ahead and know that that's what the road is going to look like, I think there's a path to being a success story. In medical technology, I think, you know, frankly, there was a tremendous amount of capital being deployed over the last five years or so. And there are a bunch of incredible ideas that got funded, that are really more point solutions, and may not ultimately be able to support the types of valuations or the long term value that, you know, venture community is expecting out of those companies. And so I think you're gonna see a couple fold, you're gonna see a couple companies, hopefully, life is one of them, that continues to do things best in class the right way, thinking strategically long term, and working towards towards those goals with the expertise in house, and then you're gonna see some level of consolidation, because we don't need a million different point solutions for all these different subcomponents, they should really all be, you know, part of the same ecosystem of solutions that can help, you know, improve the whole the whole sector. So those are some of the things that come to mind when thinking about, you know, how do you how do you not burn out? And how do you match your capital raising with your burn with the stage of business that you're at, especially within healthcare.

Griffin Jones  36:35

You talked about needing to be prepared for that long haul, does that mean you need to match with VCs who are also prepared for that long haul? And is that something that's realistic to expect from VC? So you talked about the art of managing the product market fit. And when you bootstrap, it's it's pretty obvious. So you run out of money, then you figure out a way until it starts making money. When you when you're playing with other people's money it's different. And you mentioned that because healthcare has such a high regulatory barrier to entry move so much slower than other sectors might be used to, should we expect to see VC firms and not just like, you know, arms of VC firms, but should we expect to see VC firms that are exclusively dedicated to healthcare? Is that an upward trend? Is that not happening as much? Is, is that necessary? Because if it does take this long, then you need the funding to match how long it's going to take. And some people might not be ready for that? 

Paxton Maeder-York  37:37

Yeah, you know, I think, first I'd say that there are a variety of different types of investors. And I think that's really important for anyone going out and trying to fundraise, right? There is, you know, there are folks that only do enterprise deals. There are folks that don't touch healthcare. There are a lot of investors that don't particularly want to invest in women's health, for example, or human health, you know. And I think whenever going out to fundraise, you really have to be thoughtful. And again, going back to this dating theme of figuring out who the right folks are to be talking to and, and who has both interest wherewithal and long term vision that can share, you know, kind of where you want to take the business as a leadership team. To answer your other question. Absolutely. There are plenty of healthcare focused founders, or investors and founders. And I also think that the personally, I've found that the style of investment between East Coast and even West Coast varies, and one of the things I'm really grateful of is that I've got both East Coast and West Coast firms on my cap table, and I kind of have been able to accumulate a hybrid of those two different, you know, approaches to investing. And, you know, I think, again, it's it's really just about finding people that believe in the long term vision, see the high level opportunity that exists here, who have been through the pain point, for example, on their own, so that they know, okay, like this is a problem this, this whole sector is going to continue to need to grow, there's going to need to be better technology and analytics can an AI can play an important role on that. And and we see that opportunity down down the line. And you know, as long as the team is thoughtful about how they're spending that cash in very value creative and additive activities, then hopefully, in the long run, you're gonna go out and achieve that goal. So yeah, I mean, people talk a lot about patient capital. I think there, there are certainly funds that, you know, don't expect to return in the same, you know, eight year timeline as others. There's kind of evergreen funds, there's traditional private equity, which has a more much shorter time period of trying to get a return on their capital. So all those things need to be taken into account. But what one of the things that's been so wonderful that I found along my journey is that those investors do exist. There are definitively folks out there who come from incredible firms that believe in the long term envision and are willing to put capital behind things that matter both for the social good, and behind teams that they think are qualified to go out and make that type of difference.

Griffin Jones  40:09

Are you raising money right now? Are you moving on to a Series B?

Paxton Maeder-York  40:12

We're not raising at the moment, we're still heads down and developing a ton and, you know, working with our close partners to get our products out into the field, but we will continue to raise over the course of the lifecycle of the company. And, you know, I think there are a variety of different applications and use cases for that capital beyond just keeping the lights on and continuing to pay salaries and make sure that we're, you know, ever developing more and more of our core platform. You know, there's, there's lots of applications that you can use capital at the right times to supercharge and enhance what you're building. And given our goal is to supercharge and enhance, you know, the clinical care in in practice, the same thing goes for the right investors who have the right almost investor products that can work with great companies like ours.

Griffin Jones  40:57

So your last round your series, they finished when?

Paxton Maeder-York  41:00

A year ago in March.

Griffin Jones  41:02

How much has the market changed in terms of venture capital in the last year and a half since since March of 22? From what you can tell from your, your investors now, your peers, what's happening in Silicon Valley?

Paxton Maeder-York  41:20

So, you know, you can you can read the investor reports, you know, I think we're all looking at the same numbers, there certainly has been a decline in, you know, in both digital health IPOs traditional tech IPOs share prices are down at times, although they they fluctuate, obviously, and certainly, you know, smaller rounds, and where you're expected to be by the time you raise that round has, has evolved. Having said that, you know, I think there's an old adage that the best companies are built during downtime. And I think that's true, I think there was certainly a period where there was so much capital that was being deployed so quickly, people weren't getting to know their investors, and the investors not necessarily getting some of the portfolio companies that, you know, there was a lot of stuff that maybe shouldn't have been funded during that period. And I think those types of businesses that don't have kind of a strong long term goal, and you know, industry or market tailwinds behind them, I think some of those may struggle in the next year or so as they start to ramp up.

Griffin Jones  42:18

Are they still getting funded? Are you still seeing jokers get funded?

Paxton Maeder-York  42:22

I would hesitate to call anybody a joker. But you know, I think to a lesser degree, although, you know, I think Artificial intelligence has certainly become more of a hype term recently. We've been doing this for three years. I think the underlying data science that is backing this type of technology is super solid and real. Having said that, you know, I think unfortunately, there will be folks that may not have spent the time to really become experts in data science, are going to start companies and I don't just mean this in healthcare, I mean, this across the entire tech ecosystem. And you know, hopefully those companies don't, you know, do things that may harm the overarching ecosystem of technology implementation, which is really what we're talking about here, right, you know, AI is, you know, is a is an ever evolving field of data science. And it's based on having these large datasets and how you apply those datasets to real world problems, is, you know, where rubber meets the road, and you're building real businesses. So, you know, I think, I think there will always be some level of FOMO and venture hype that funds different types of companies. But, you know, I think for the folks that are in healthcare, specifically, infertility and IVF, is not going anywhere. If anything, we know that we're not meeting the level of supply that we need to meet the demand. So you know, I think it's a it's a fairly, you know, robust bet to make. Alright, there's, there's a real need here for the population, it's a growing market, you know, there's opportunity to bring technology and best practices, not only from across the United States, but also internationally and globally. And software and AI has this like, really remarkable, unique capability to make that a reality, and a in a very usable and impactful way. So I think from a high level perspective, you know, the, the trajectory in the vision makes perfect sense. I think, of course, then it comes down to well, are you going to be a best in class company? Are you going to do it with high integrity and really do all the clinical validation and make sure that what you're building is, is robust? And that all comes down to you know, how experienced is your team and whether or not you guys have the right mindset to go out and march towards that long term goal.

Griffin Jones  44:38

You haven't acquired any companies in this three year tenure have you?

Paxton Maeder-York  44:42

Not yet. M&A is certainly something that we are considering and when will probably will be part of our story in the long run. But right now, we really view what we're building today the Alife Assist platform, which, you know, is built for reproductive endocrinology to optimize ovarian stimulation embryology team seem to automate and digitalize their platforms. And then, you know, clinic management, that system, we believe is the core of a lot of opportunity to continue to bring this type of value to the clinic.

Griffin Jones  45:11

Did you consider any M&A and building that system?

Paxton Maeder-York  45:14

You know, we have along the way, we've looked at a number of different opportunities, and nothing is really, you know, positioned itself to us in a way that made us feel like this is something that is going to be accelerating our trajectory into the market. You know, there have been other companies that we've partnered with some companies have already come and gone. There, there are companies that you know, and team members, in fact, that used to work at other companies that we've kind of encouraged them to, hey, join our story, because we think we've got a great, you know, great team, great backers, and the right vision and the right resources to go out and get it. But you know, to date, it hasn't made sense to acquire any smaller companies yet.

Griffin Jones  45:54

I'm seeing if I can glean from you any kind of criteria of when it's too early. It seems to me that some companies are acquiring companies too early, but I'm just, that's just me, being a Monday morning quarterback, I don't know. And so I'm trying to see if if there is like any kind of criteria set where it's like, now this, you have to wait until X until it really makes sense to start paying for other companies.

Paxton Maeder-York  46:21

Yeah, I mean, you know, I think there's a difference between, you know, acquiring another business and merging with another business. And, of course, you know, the stage of business, you know, company that you're at, will dictate, you know, there, there are, you know, two plus two makes five situations where, you know, one company is kind of struggling and other companies doing well but kind of struggling together they have a much better shot. I think for for Alife specifically, and I can only really speak from our position, I think there are a number of different opportunities that we're constantly seeing out in the market, and that we know long term we would like to either partner with, acquire or build ourselves. But the way I think about it is I really want to hang those different types of new opportunities off of a core foundation that we've built. And right now being Series A, and having recently launched our products and are now you know, you know, working very closely with partners to continue to push them out into the market and get real world utilization, they're constantly getting better as we get more feedback. You know, that's, that's kind of stage where we are, as the as this platform, you know, hopefully resonates with our end customers and becomes adopted. And it's something that is really impacting clinical care for doctors and patients alike. You know, that's where we can start having really interesting conversations about like, what would be additive to our platform, what are some other things that we're in a unique position with either our data or the infrastructure we built, that is going to make us even more competitive if we either acquire or build some of these additional business opportunities on our own. So, you know, I think post Series B, Series C, that's typically where you see a lot of tech companies starting to do real M&A, with the exception of kind of early stage seed combinations that, you know, for folks that are just trying to continue to survive as businesses,

Griffin Jones  48:06

Let's wrap with the team and the tech stack, I don't expect you to go into anything proprietary about your tech stack, but to the level of detail that you can share, what does it look like just for someone that it might be a fertility doctor has never worked for an AI company? What does the whole tech side, which is the majority of what you're delivering, look like? Because there's a product teams, the the CTO, the tech stack, to the level that you can share? 

Paxton Maeder-York  48:35

Yeah, I think, you know, without getting too too deep into the technical side, because, you know, I think people are probably less interested in, you know, what, what back end resources were using as a company, I think that one of the things that can, that can be very, very useful is thinking about building a company almost the same way as you think about building a product. Applying engineering mindset to your organization. And so, you know, for us, we when we started the business, you know, we really were focused on R&D, and developing the early platform. And so you know, what that looked like from a leadership perspective is we had a had a software, I had a product and I had a data science, and each one ran their own divisions and data science was building new algorithms was publishing papers, was speaking at conferences, the software division was actually building the core infrastructure, taking the code from data science and haven't you know, making sure that it was going to run reliably, you know, making sure that we're doing all the documentation and testing, verification, validation testing is super important and medical technology. And then product was really focused in both the design of the front end user interface as well as you know, talking to all our partners and testing and making sure that what we were building was fitting that Venn diagram we talked about earlier. As the company has evolved, you know, we're constantly changing our organizational structure to meet the needs of the business at that base. So as we started to launch product, we brought on a head of Clinical Affairs to run a lot of our clinical studies and RCTs. We started to build relationships in Europe, so we have a head of head of EMEA based in Zurich. We actually have a wholly owned subsidiary based in Zurich to build partnerships across the EU really focused on trying to bring this vision of best practices from around the world to that patient that walks in the door at a specific clinic. And then we consolidated some of the units as well as brought on now head of commercial that's going to help us continue to drive the products and their adoption. So it's kind of a constant, you know, re-evaluation of where we are with the phase of the business. Are we in R&D? Are we commercial, you know, switching over to early commercial phase? But you know, I think really making sure that your team is structured in a way that allows you to go out and thoughtfully and efficiently go out and build what you want to build is, is I think paramount when you're starting your own company.

Griffin Jones  50:55

Paxton Maeder-York, thank you very much for coming on the Inside Reproductive Health podcast.

Paxton Maeder-York  51:00

Thank you so much for having me. It was a pleasure to be here.

Sponsor  51:03

This episode was brought to you by Embie. To discover where your time is going and how Embie can transform your clinics efficiency, visit us at embieclinic.com/report. That's embieclinic.com/report. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertilitybridge.com to begin the first piece of the fertility marketing system, The Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.

197 Human Trafficking in Donor Egg IVF. How to Protect Your Clinic and Patients Featuring Diana Thomas

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


This may be the most serious topic we’ve discussed on Inside Reproductive Health, and it is a vital conversation to be having in the fertility space. The buying and selling of human trafficked eggs.

Diana Thomas, CEO and Founder of The World Egg and Sperm Bank and an early recipient of donor egg IVF, addresses the concerning rise in trafficked eggs reaching clinics and patients, along with the associated legal and ethical concerns.

Diana talks about:

  • The spike in donor eggs from developing countries (And how many of them are flagged as high risk for human trafficking)

  • How victims are coached to amend their profiles to look upper class (Reducing suspicion of exploitation)

  • Specific examples of different egg donor agencies and banks where there’s contradicting information regarding donor information.

  • A new Human Trafficking Act (Including the legal and financial implications)

  • TWESB’s strict protocols to minimize the risk of providing trafficked eggs to their patients

  • Her checklist any clinic can use to help ensure they are not buying and selling trafficked eggs


Diana Thomas LinkedIn
The World Egg and Sperm Bank

Transcript

Diana Thomas  00:00

Prevalent isn't even a good enough word. It's flooded our markets. And it's amazing to me that doctors and radiologists and patients don't have a clue what's going on the certainly that everybody says well, the aids are cheaper from there. But those savings are not being passed on to the patient they're still paying $22,000 per cohort.

Sponsor  00:22

This episode was made possible by our feature sponsor The World Egg and Sperm Bank, head over to www.theworldeggandspermbank.com/protect and download their free due diligence checklist to ensure that your program only sells eggs from donors that have been safely and ethically protected. That's theworldeggandspermbank.com/protect. Today's episode is paid content from our feature sponsor who helps inside reproductive health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

Griffin Jones  01:12

This is one of the most serious topics we've ever covered on the inside reproductive health podcast off the top of my head from what I can think of from 200 episodes. It's the most serious it has to do with the trafficking of young women and exploiting them to sell their oocytes unsafely at a profit a huge profit. To me, it seems the worst case scenario is this is something that's happening with hundreds, maybe even 1000s of cases. And the best case scenario, as far as I can tell is that clinics are very vulnerable to using and selling eggs from women who've been victims of trafficking because from what I see the chain of custody isn't secure enough. There's too much movement, too much uncertainty, I'm not qualified to say but my guest has done a lot more research in this area. Her name is Diana Thomas, you know, or is the founder and CEO of The World Egg and Sperm Bank. Not only was she among the very first of agencies and banks, she was among the very first patients to be the recipient of donor egg IVF. She found her own donor made her own contract had children from donor egg IVF then started doing that for other fertility doctors and other fertility clinics who recruited her to find other donors for their other patients. Diane talks about the changes that she made in 2014, 2015 as vitrification became more popular, but then people were stimulating differently. They were freezing differently. They were shipping differently. They're all these different spokes in the custody wheel. So her egg bank centralized everything stimulation shipping recruitment screening protocols gave a really tight bead on quality assurance around 2018 and 2019 is when Diana saw a really large spike of imported eggs coming into the UK and Canada and the United States from developing countries. Many of these countries had been flagged by the US State Department for being high risk for human trafficking. Diana says it's not just a correlation. There have been articles about very large arrests happening with human trafficking and coercion for egg donors. The most recent one at time of this episode Aug. 23, just happened on the Greek island of Crete. She references the pH dissertation of a whistleblower from a Ukrainian clinic who talks about how Ukrainian records are falsified. Women are forced to sign consents, they're pushed into doing far more retrievals than you would she gives one example where a woman did 24 Egg retrievals to an estimated 600 eggs 480 that are viable at cohorts of six maybe 40 children from one Ukrainian donor and according to the reports of the whistleblower, that donor was paid $100 per donation where the other parties including the criminals, but also including the clinics and egg banks made a lot more money than that. Danna talks about Ukrainian clinics trying to sell off eggs at $200 apiece because of their compliance issues with the FDA. So they sell through a Canadian cryobank Danna goes through examples from different egg donor agencies and banks, where there's contradicting information. She said she lives in one place. But then the other part of the profile she said she's Ukrainian doesn't have a green card yet. And another profile says that she's seeking asylum. She talks about how donors are coached to amend their profiles, so they see more upper class so that American Canadian and British and Australian recipients are less likely to suspect her exploitation. So as Diana what she does differently, she talks about the residency requirements for her donors. She talks about the identity requirements for donors, the multi-phase personality test that's required from each of her donors, the human trafficking protocol protocol that they have for their donors, how she can be so much more certain that their donated eggs are coming from women who have not been trafficked. There's of course huge ethical implications. There's legal implications down to the clinic and the provider Diana talks about a new human trap Thinking Act and the legal and financial implications from that. And I give a business and a public relations warning. Many of you are CEOs, many of your practice owners imagine trying to sell your practice. Imagine trying to sell your fertility network to another network or buy another network to go public with your network done all this marketing gotten all this by in about your mission and values. And a major media investigation reveals that donor eggs that you're using for big profit are coming from women who've been coerced and exploited and trafficked. The human concern comes first. This is something you have to look into The World Egg and Sperm Bank has a checklist for your due diligence for protecting yourselves from human traffic tags, protecting your patients from that ultimately protecting the donors. That checklist talks about ownership history, donor sources, chain of custody accountability, practice liabilities and donor care. Use that checklist as an agenda for meeting with your leadership team. You can get it on The World Egg and Sperm Bank website, we're gonna link to it on this episode page link to it in the ads we run with this episode, we'll link to it in the email that this episode comes out in. But do your due diligence because this could be a major threat to your company. Now on to my conversation with Diana Thomas, CEO of The World Egg and Sperm Bank. Ms. Thomas, Diana, welcome to the Inside Reproductive Health podcast.

Diana Thomas  06:17

Thank you excited to be here.

Griffin Jones  06:19

I could spend probably an entire episode just talking about your background. So I don't want to spend all of the time in there because we have an important topic to touch on an important topic that we should all be concerned about we that we should all be investigating and making sure that safeguards are in place that it isn't happening. But your background is really really interesting to me. So I want to give a little synopsis and you tell me if I got it right. But sounds like you were living in Canada in the mid 90s. It's around 1995. You need assisted reproductive technology, the waitlist in Canada for IVF is several months and no donors are available there at that time. You move back to Phoenix, Arizona, where you're originally from, they can do donor egg IVF. But they're not doing Ixy or anything and they don't have like their own egg donors available. They don't have banks that they're working with. So they tell you, yeah, sure, if you can find one, we'll we'll use that person's egg you recruit your own egg donor from the Arizona State campus. And then you write your own contract for for that there wasn't like third party contracts at that time. So you write that. And and you went, you decided to go with open identity from the very beginning. How close am I to having that, right?

Diana Thomas  07:54

Yeah, pretty close. Except I was in Canada and in the mid 80s when I actually started in IVs. So it was right at the beginning of really that then creation of the industry.

Griffin Jones  08:05

So you start you were you had gone through some cycles, but it was 1995 when you did your first donor cycle in in red. Yeah, Sona. Yes,

Diana Thomas  08:13

I went through phase one. Yes. Yeah. So your learning was after 15 years of Toronto.

Griffin Jones  08:19

You're learning everything on your own at this point as you're going through it. And then at that point, someone says to you, Hey, can you do that for our other patients? Was it the clinic that you had went to see? Did they tell other fertility doctors? How did fertility doctors start calling you and asking if you could find donors for their patients?

Diana Thomas  08:42

It did start at the clinic that I had conceived through. And I also can see through my second children, my twins through another clinic, but basically it was the doctors from those clinics calling me and then I don't know, we're just really spread. I started getting phone calls from intended parents, just begging me to help find downers.

Griffin Jones  09:04

In the beginning. Would you say that you were an agency rather than a bank?

Diana Thomas  09:09

Oh, absolutely. There. Yeah, there was no egg freezing at all at the time, not until 2005 2004. So it was it was a fresh donor agency that I started then.

Griffin Jones  09:21

And so it was about 2015 where you started to make your company into an egg bank.

Diana Thomas  09:29

Now we became an egg bank in 2004 was slow freeze technology. And we had our first baby that was documented on Good Morning America in 2005 through Frozen egg out of Lexington, Kentucky. So we began recruiting donors just for the bank. But at the time the slow free technology wasn't nearly as good I think pregnancy rates around 32% At that time, so we switched over to vitrification in 2009 And what were freezing eggs then at the same time, up until about 2010, I was also doing fresh donor cycles around the country, taking downers to different blog posts, and

Griffin Jones  10:12

So vitrification starts to take off. And then in 2014, I had read something where you said, you started to find out that quality couldn't be assured. And I think that has something to do with different eggs being vitrified at different clinics sold to different banks, and then being incentivized on as many retrievals as possible and tied to the sale of the donor egg. So can you tell us about what you started to see in 2014?

Diana Thomas  10:44

Well, you know, we were an egg bank, probably six or seven years before any other egg bank came onto the market. We were egg banks before. Actually I was I was a donor agency before there are any hands around guidelines. So we're now contracts. So as you know, there wasn't even FDA testing on donors at the time, in those early days. So I started to see that the business model that other people were forming, was to do outside networks retrieval, say contact various clinics to do their retrievals. And I tried that with a couple of clinics to start and I realized, there was no way to really control the quality i i couldn't depend on if I worked with this doctor, he would hyper stem the dollars that I worked with this doctor, they would only get five eggs, because they were afraid of high percent. It just there was no way to control the actual process for the donor. And because egg freezing was so very new at the time, not a lot of people knew how to do it. And we would send in our own embryologist to to freeze it at those network clients, but we still could not. We just couldn't track family limits, we couldn't do all the things we want it to do. So I said we just have to start a whole new business model. And that is a centralized model, which contains everything on location from recruiting, to stimulation to freezing, to shipping, and we could manage all the family limits all the testing, all the egg freezing, and all the shipping. So we ended up having incredibly good success rates doing it that way.

Griffin Jones  12:23

So that's what I was thinking of what happened in 2014 and 2015. So by 2015, you are doing everything the same way protocols screening stem, vitrification storage, the way you ship that's all uniform across the board.

Diana Thomas  12:39

Correct. Same staff, same experience, people. Yep, same protocols.

Griffin Jones  12:45

So it this time, you're really starting to build quality assurance that is locked down. And because of that, you can probably see when ever there's some variance in that quality, or if there are gaps in the QA piece of it. And then you start to see a trend happening in 2018 and 2019 have of eggs coming from other countries. Tell us about that. Or maybe not even other countries, but particularly from developing countries.

Diana Thomas  13:18

Yeah, I I really was rather unaware of it until probably two years ago. But I know all of the reading and research I've done it did start much earlier. In fact, there's a clinic in Chicago that's identified in the book, The Red market, that talks about donors being shipped into Chicago and retrieved and then sent back home. So it's been around a while it's just become so incredibly overwhelming. I mean, it's right now developing country, extra developing countries and sperm now, by the way, is really flooding just flooding the US market and the Canadian market and the UK market. And it's really a lot more information has come out about what's going on behind the scenes. That's truly alarming. very alarming. Why

Griffin Jones  14:09

2018 2019? What was it about that time period that this trend started to happen?

Diana Thomas  14:16

I think it was the globalization, the economic globalization and IVF really ticked up. And most of this, most of this is really driven by global funding and global purchases of US companies that Canadian companies and UK companies. So yeah, they have strong ties in European countries and other countries. So they're, they could see a huge profit margin by doing it this way. And I'd love to give you an example. If you're ready to hear one anytime. How much money people make up first.

Griffin Jones  14:49

Yeah, hold on to that example for one second, because I want to ask you, you said that it's alarming. Why is it alarming?

Diana Thomas  14:55

Well, any human trafficking should be alarming to anyone. There The fact that all of these eggs are coming from, from countries well known for human trafficking, human trafficking stems from organized crime. And that you can go on to the government, US Department of State and see annual reports published about every country's human trafficking behaviors. And statistics is well known and well documented. There, they estimate 60,000 Russian women are human trafficked a year and prior to the war in Ukraine, at least 6000 Ukrainian women were and those are the ones that are reported. So it's not a thing. It just happens once in a while, or maybe one donor is treated poorly. I know, the 1000s that are listed on websites, you know, downer concierge, boasts 25,000 donors.

Griffin Jones  15:50

So there's alarm because these two things are happening in parallel one, you have a big rise in eggs coming from developing countries. And they also happen to be countries where human trafficking is a really big problem. And so

Diana Thomas  16:07

It's been documented, as well, there have been people have documented these specific donors, and specific instances of that of this. And I have plenty of references I could make to some of those documents. But it's also that's yeah, human trafficking is it's everybody should just stop there. But then there's also who's telling recipients that this is going on, and who can validate any of the data, medical data. There have been two recent arrests that show that the the medical data is falsified. For egg donation for genetic material being sold to the west. One article just came out this month 71 donors that were rescued from an organized trafficking ring and gray. So I think that, you know that the cycle we don't understand is these women are trafficked. And they're trafficking with fraudulent promises of vacations or jobs or or were and then they're putting the dancing clubs and prostitution, with Ed backing on the side. So do we really think that these some of these women don't have HIV? Who, whose blood is being tested? Who's Who's tracking the chain of custody for any of the testing that's gone on in Europe that each and then track that the actual documents down much less? Now, the chain of custody especially? Well, I'll wait for you to ask more questions. 

Griffin Jones  17:40

Tell us about the example you're thinking of,

Diana Thomas  17:43

Well, if there's a great documents, if people are really, really don't believe this is going on by pulling up the lens, the Lascaux who's did her dissertation and Indiana University in 2021, and lived in Ukraine, and worked at a Ukrainian egg bank for three years. So she came back with all kinds of interviews and documentation and explanation of how the process works and how records are falsified and how donors are, are called the consent sign these consent so they will can't donate. They're not going to get paid or just the coercion an inherent in almost every step of the process. And coercion of vulnerable women is a definition of human trafficking. So Natalia, for example, was interviewed by Polina and she donated so far and 2021 24 times all the records that we get them on these women's say, donation up to up to six times. And they were in four or five different countries, she got paid about $100 per donation. So that's $2,400, she produced around 600 eggs on an average cycle, maybe 480 will mature out of those 24 cycles. So that those 280 couples, six cohorts of six those 280 couples around the world, meaning there's probably 40 children from this one Boughner that's just the egg side of it, but the money side of it is she gets walks away with $2,400. The broker pimps that bring them in and the doctors that retrieved the eggs are making $7,500 per cohort of six. And I know that I've got emails from people offering me those prices. So they're making $600,000 Right there. Then they sell the eggs to us egg banks and Canadian egg banks and Canadian doctors who turn around and sell them for 20 to $2,000 to their patients. So the doctors in this country and the UK and Canada are making $20,000 off to off of a single board of eggs. So around this stellato was worth around $2.6 million. And we are supporting organized crime in that purchase.

Griffin Jones  20:07

How does the report know discover that this donor had did 24 retrievals? When you know, it may have been reported that she did four, six, how did how did they discover that she had done 24.

Diana Thomas  20:21

She works in a clinic that sent her out. And that was she wasn't the only one she documented. She documented a number of them. I just picked that one out as an example. So some were up to 15 times, some were more than that. They go they go to Israel, they go to the US, they go to Spain, and they retrieve in Ukraine.

Griffin Jones  20:44

So this pullin of Valeska Am I saying her name correctly? Polenta malesko. She's a whistleblower. She works at a Ukrainian clinic or worked at a Ukrainian clinic. And this is what she's observed from the patients coming through.

Diana Thomas  20:57

Well, it's also her PhD dissertation. So it wasn't just journalism. See now, and she didn't get her PhD, she had to defend this dissertation.

Griffin Jones  21:09

So you have someone that is getting $100, that when we know that the total compensation is a lot more than that, and that's going to different people, it's going to the people doing the retrievals is going to people that are bringing her in. And that's also way more than it's way more retrievals than we would expect to be safe for, for anyone, right? And so So are we are we mostly worried about this happening with women that are in these particular countries? So if it's Ukraine, or Georgia or Russia, or are we worried about the trafficking that's happening to Ukrainian, Georgian Russian women? Or are we also worried about people that are being trafficked into those countries like Turkmenistan, or the UAE or other countries where people are being removed from and brought into which is it Are they are they both are concerned,

Diana Thomas  22:10

all are concerned, because they're all forms of human trafficking and where we're supporting organized crime by buying those eggs, and supporting the cycle of violence and coercion with women around the world. It's also, if you look at the US Department of State report on Spain, for example, it's considered one of the worst locations for trafficking women into Spain. And they're coming now from Bolivia and Chile and Venezuela and Brazil, and Colombia and Nigeria. And that's it's all documented in the US Department of State records that this is going on. So these women get into these places, they also document that they're confined in apartments. So they're used for prostitution, you know, it's a model that the organized crime is calling the renewable resource model. So these women are considered renewable resources because you can use them all up and use them again and again and again. Prostitution, modeling, dancing, egg retrieval, surrogacy, the one that was arrested this month was for all three of those things. Prostitution, surrogacy and egg retrievals

Griffin Jones  23:21

Can you tell us about that arrest? I was unfamiliar with this story. Oh,

Diana Thomas  23:25

yeah. It just came out on August 20. Around that time, I think. Yeah, I think I've gotten on my on my LinkedIn of that. But basically, doctors, secretaries, embryo embryologist organized crime, in particular persons were all arrested for because of 98 women that were being used for prostitution, surrogacy and egg retrievals for egg donation. And in the arrest, they found all the medical documents falsified, consents falsified. It was they rescue these women from confinement? Was this also in Ukraine. Now there it was in Greece, and which is really interesting. It's the second arrests, it was large like that the other one was in 2019. There, but there were women from Russia, from Ukraine, from Latvia of Georgia, and other countries that were sent to grace to be retrieved.

Griffin Jones  24:24

And so and Cyprus is an area that has been dinged for human trafficking in the past, and neighbor to Greece. And so women are both vulnerable in these countries, and then they're vulnerable from other countries that go through these countries. You have have I've given talks before where you go through profiles of different donor egg banks, and there's contradicting information in the profiles you know, the things will say like, she's in London or she's in Florida, but they Then you read through the rest of the profile, and she's in the Ukraine or she doesn't have a green card, it says, Green Card pending does. So it's like, Well, is she? Is she actually in Florida? Or like, or are they in Florida? Like they're and and you know, there's ones where it's like it says, seeking asylum. It says that in the profile. And so tell us about these examples?

Diana Thomas  25:25

Well, I mean, there are 1000s of them. And you know, I, people say to me, Well, who's doing that in the US? And I basically because I would say who isn't? We really, I believe that almost every egg bank is and they're also shipping them to Canada to cannamd cryo bank. And we had somebody approached us at ESHRE, from Ukraine, trying to sell to dump the eggs for $200 because the FDA is coming down on them, and said, you have to buy them from Ken Ham cryo. So send your patients there, we'll ship all of our eggs to Canada. Because it's there's no FDA in Canada. So there's no there's no, there's absolutely no verification of the of the testing that's going on from these donors. So they go from, you know, Ukraine, to Poland to Spain, to a bank in the US to a Canadian egg bank in and out of tanks. And people are buying them and have no clue where they originally from. And there's no disclosure at when they're when they're purchased by recipients. That that any of this is going on, people assume that if it's in the United States or Canada, it's legal and it's healthy, and it's safe.

Griffin Jones  26:43

That seems to be a big chain of custody. Yeah, that can be easily obscured. Because yeah, it's it seems to me that, that you can feel like, Oh, this is the source, but you don't actually know the source because it didn't come from this agency or this clinic and get shipped to this clinic or this agency. It was brokered by yet another intermediary that was trying to unload Oh sites for reasons that you thought, Oh, we're in Ukraine, and things are really bad. And we're so we're going to try to sell eggs at a discount, and but you have to go through this other person. And ultimately, the patient really isn't aware of, of that long chain of custody. How familiar are the clinicians with that long chain of custody? Do they know where eggs are coming from?

Diana Thomas  27:35

I really don't think so. No one has really stopped to ask the question until recently, we've been trying to educate people about asking questions, which is why I've done a checklist for people to start asking questions. In order to determine where the ACE came from, or or if they have answers. I did an online survey in April, just a quick, quick and dirty to embryologist Do you know the source of the anchor warming? Only 33% of them and the end was only 200. So it's not it wasn't huge, but it's a pretty good indication. embryologists are really honest, if they do answer directly. And of those people that that did. Now, they knew that 50% of them they thought came from the US. But that's because the US egg bank name is on the shipment. And the other 50% knew they came from Eastern Europe, because they sponsor a clinic, or from the UK, which is really just another transit country because they don't retrieve eggs and send them out from the UK, and, and Spain. So people are aware that it's happening, and they're entering that data as a soccer clinic and the sorry.

Griffin Jones  28:48

And so I think that the any egg bank would say, Oh, well, they do say because you go to their website. In fact, one of the examples that you had in, in your talk, you point out all you show the map of where they're getting their donors from from a month. I think it's like 20, they say 20,000 donors available is on. And of course right on their homepage. They say each of our egg donors is required to complete a rigorous application and screening process prior to being added into our database for their safety and for the health and general health of your future baby. We document and verify every egg donors identity, education and mental physical and reproductive health. Why is that wrong? How can how can it how they're all going to say the same thing? What in your view is insufficient about what they're doing? 

Diana Thomas  29:49

Well, it's all a lie. They're marketing to the Western market, which you go to a Polina dissertation she talks about how the session with the psychologist is how to how to amend their profile to make the look like educated white middle class women so that people in the Western world don't feel guilty, getting eggs for poor abuse women who are not educated. So they falsify their talents, as you saw in one of the donors who had spoke five languages, including ancient Latin, played jazz and classical piano, and had a real estate degree, but she's a freelance model. It you know, really I? And they are saying they're not lying about any of that stuff. When you have done people getting arrested for false records, and who, who actually validates any of it? How do you know the eight you can actually the blood you get is from the same donor who's anxious you get? Because they say so is that gonna hold up in court is that going to hold up to the FDA and FDA audit will look at their website, they say they do all is, if they want to steal it, it's it's, and yet, people like us, who actually do it all the right way, are held accountable, and can be prosecuted for not following the law.

Griffin Jones  31:15

I know what's going to happen after this episode comes out, people are gonna hear it, CEOs of networks are going to hear it, doctors are gonna hear it lab directors are gonna hear it and they're gonna say, Oh, crud, they're gonna go to your website, they're gonna download the checklist, and then they're gonna go to whoever they're buying eggs from right now. And they're gonna say, how do we know that you're that you're not going to? Or how do we know that you're actually safeguarding and making sure that these are from donors who are properly verified, who are safeguarded or not traffic? And those egg banks are gonna inevitably going to say, we this is what we do, we've got it all under control. Are they lying, in your view? Or is there something that those egg banks aren't doing? Even if they have good intentions to properly verify the chain of custody?

Diana Thomas  32:08

Well, the question is, are you going to stick your clinic reputation on that? When when a baby is born and out to your clinic with HIV? Are you going to say, well, they told me, I believe them? There is no source documentation that can be discovered in a court of law. You know, they there's documentation that the stuff is falsified? And do they do it for every person? What the question is who, who is a third party that's not making money off this, this auditing them? There is nobody. So when they say that they are FDA registered? Yeah, you can be FDA registered, and the FDA has this wonderful little loophole that's abused by Western clinics is that it says if you sponsor he sponsor that clinic in Ukraine, you're verifying your personally stating you believe that they're actually doing FDA compliance. So they send the eggs over, but there's no documentation. And if they do get documentation, how do you know the chain of custody for the blood work that was done? But that when an f1, and f2 agent goes to your lab, what are they looking for, they're looking for, for real proof that there's infectious disease testing going on for this particular set of A's. And that that's just not going to be there?

Griffin Jones  33:33

What would proper identity verification look like?

Diana Thomas  33:36

Well, I'm not sure that really matters when you traffic, your trafficking, whether you identify them correctly or not, you know, the act of trafficking, supersedes all else. Because the act of trafficking is is against the law and is punishable. And if it doesn't mean that you're not trafficking, because you bought the eggs you didn't know she was trafficked. You buy stolen goods, you have to return them. It's it you are accountable. You're liable. You're transferring those eggs into your patient. You're the last person to say well, yeah, I trusted them over there. I believe that and how, how do they know? I mean, we're talking about Ukraine, but they're getting eggs to Bolivia and Chile and all different sets of all different countries. So they believe all those doctors, they just believe everybody. That's okay. You that's what's going on. When what is documented, there's so much human trafficking going on in those places. There's specific instances of it. It's just all over the place all over the internet, if you want to better the US Department of State.

Griffin Jones  34:42

Yeah, especially in countries that are war torn like Ukraine or bad state actors like Russia, where no one trusts what's coming out of Russia typically. And so why would you trust the so if you didn't trust the Olympics, if you didn't trust fraud and You know, involvement in in other countries and, and and sabotaging other people's internet infrastructure? And then, but but you're going to say no, but for sure we know that they're safely doing egg donation. Yeah.

Diana Thomas  35:17

Any organized crime drug lords run Bolivia and Colombia? You know, it's not really a disconnect there.

Griffin Jones  35:26

Yeah, it seems it seems too high risk for for my taste to be having those eggs come from other places especially because to your point, you could have the proper identity verification, but that it okay this is the donor Diana Thomas but we didn't know that Griffin Jones or someone else didn't make her come here and is stealing her compensation and then forcing her to do that over and over again and, and other things. And so what is it about what you're doing at the World egg and sperm bank that you feel very confident that we know our donors aren't coming from human draft trafficked places, we know that they're not being coerced into doing this, we know exactly who they are, where the eggs are coming from, where they're going, what is it that you're doing differently?

Diana Thomas  36:19

Well, first of all, we do everything in one location. So we have one building, every single donor comes through our door, we see them, we know them, we take their ID, which is usually a passport and a driver's license. And another form of ID if we can they are interviewed here they are interviewed independently outside of here by psychologists. They do MMPI to show that they're whether they're lying or not. They're also interviewed by doctors that are also on contract outside of us. So we're not trying to manipulate the outcome. And anybody who comes in the store from the United States, we only use donors that are US donors who are residents, because you have to be able to ask them back, if you're going to follow family limits and international laws. We actually limit our donations to 10 families worldwide for egg and sperm. So these women come in, we know who they are. But we also these women have opportunity. They're educated, they have an opportunity for other work. They have legal support if they feel that we're doing something wrong. And every document and every person and procedure we do in here can be discovered in a court of law. So we are accountable from beginning to end for our donors. All of your donors are us owe them. Ali, I think we've had, we have had a few Canadian donors, but I would say in the end, 10 years, we've had like three.

Griffin Jones  37:50

And then they're all donating at the lab in Phoenix,

Diana Thomas  37:54

all of them are retrieved in our one location. And they're frozen here. And they're shipped from here. And so there's no other how we ship tail, there's no excess handling of the eggs, they go from our lab, to the clinics lab.

Griffin Jones  38:10

So you can be a lot more sure of who they are and where they're coming from. When you said MMPI that was the first I heard of that you said that it helps to detect if they're, if they're telling the truth or not. Tell us more about what that is, is the first time I'm hearing of it. 

Diana Thomas  38:30

Yeah, I started it when I started working with egg donors in the 90s. But it's MMPI is multi phasic personality disorder tasks that psychologists use. So it's a, you know, 700 questions that you have to answer in an hour. So it detects consistency. Or if you're misrepresenting yourself or you're trying to make, make yourself look to do but it's analyzed in a program that psychologists have been using for decades and decades, and identifies people that have compulsive lying, or they're borderline schizophrenic or their various disorders that show up in that testing.

Griffin Jones  39:07

Is that the same thing as the Minnesota some Yes, yes, we have now, it was like 561 is okay, I just was so I've taken that before years ago, probably 20 years ago. It's a 567 questions. I think it took me way longer than our if I recall correctly, I think it took me like three different hour sessions to do it. Now. I'm a slow test taker. But so when when or every single donor is doing this? 

Diana Thomas  39:36

Yeah, and they're only given an hour, that's part of the testing the parameters of the testing, because they don't want you to think about all the responses too long. That's that's kind of the whole idea, but and they'll ask the same question for you know, 20 different ways. It you know, and you you tend to go through very quickly so your answers are very spontaneous. And you're doing this forever. Every single donor are just so all of them. I've done it for 25 years. Wow.

Griffin Jones  40:07

So is anybody else doing that specific test for their donors that,

Diana Thomas  40:12

you know, I think there used to be some people that did it, I, I really haven't kept up with what other people are doing to be frank with. So I suspect they're doing that or some version of it, there's another version that's not quite as intense as well, so I think and then there's people who just sit there and talk to them for half an hour, and they write up a paragraph and that's it, which is really probably most of them. But the psychology you know, interview in Ukraine was documented as being a how to how to doctor your profile meeting and the consents. Actually, in the law state that purse traffic that's person a person that is traffic, and signs a consent, that consent is entirely invalid.

Griffin Jones  41:02

Because they want to Doctor their profile, because if they seem more affluent if they seem like they're upper class or upper middle class, then you kind of reason by proxy, I heard you say in your talk, that they it's well, you know, if they've studied at university, and they have a master's or, or they have, maybe not even those, but they speak six languages, one of them, one of which is ancient Latin, and they've studied philosophy, and they they're a jazz pianist, and concert violinist and all these other things than you think, Oh, they can't be coming from downtrodden conditions.

Diana Thomas  41:39

It's it's kind of appeals to our western culture. We don't like abuse. We don't like human trafficking. Most of us haven't been exposed to it at all. It's, it's hard to even accept that this is happening right under our noses. And people are going to start being held accountable for it. And I wish people would listen and not get in trouble over it. But if we're going to keep sponsoring, organized crime, the aids are going to keep coming until somebody really gets in trouble over. But it is a way for us to feel comfortable that that these women are not being trafficked. 

Griffin Jones  42:16

The women in some of these other countries are being coached to to elaborate and fabricate on their donation profiles, where you're putting them through a pretty rigorous personality test to make sure that this is who you say you are, and that, you know, some of these other personality disorders are screened away.

Diana Thomas  42:38

And it's also somebody outside of my organization. She's an independent psychologists. So she's got her reputation and her license to protect so she's not lying to tell me what I want to hear. Lie to tell me the truth.


Griffin Jones  42:55

Are there is there anyone else any other egg banks that you know of that that all of their donors are US residents?

Diana Thomas  43:02

is prevalent isn't even a good enough word. It's flooded our markets. And it's amazing to me that doctors and radiologists and patients don't have a clue what's going on? That certainly that everybody says well the answer cheaper from there. But those savings are not being passed on to the patient. They're still paying $22,000 per cohort. And they and they're getting something they don't really know what they're getting now.

Griffin Jones  43:31

So you are have a screening level that seems to be above and beyond you can point to a couple of things that that are actual differentiators. They're not superlatives, like we have the most rigorous screening testing is we can say all of our donors are US residents, we can say that every single one of our donors gets this MMPI test, we can say that we check all of their documentation. Do you have any other assurances for making sure that they're not coerced, though? So imagine the MMPI helps with that. And if there are US residents, we know they're not coming from other countries. But trafficking can still happen in the United States. Do you have any other assurances for for knowing that this person wasn't brought in by a pimp or an abusive partner or some other organized crime person,

Diana Thomas  44:24

We have a an official human trafficking protocol. Every dollar that comes in and is given a cup to urinate in, is tall to put a red.on The cup if they're being coerced to come in? Yeah, Firdous and Australia just did a modern human trafficking protocol for their egg bank for their clinic. So people are starting to come around to seeing that you have to mitigate it somehow.

Griffin Jones  44:50

So you take them away. Do you take them away from whoever they came in? I noticed when I went into the labor and delivery ward early or this summer that I was in, they took my wife first. And I hung out in the waiting room and then and then they came and got me and there's Are you safe? You know, where you brought here on your own? Do you feel safe to go home? Do you know all of these sorts of things? And so how do you? How do you sort of coach the woman on what the red dot means?

Diana Thomas  45:23

We actually bring them in the back away from the, if there's anybody with them, that we discussed this in the back the nurses and the doctors do, when they're doing their ultrasounds, and they're taking their urine sample, if anyone were to say, I am not comfortable going home with him, or something's wrong, we will take them into the back of the building and call the police. And, you know, that's all we can do, really. But we've never had that happen. And I've gone through at least $30,000 in my life. But you know, we also do reimbursement sheets, so we know where they work, we know what their income is, when I have somebody come in and says, I need to pay next month's rent, it's a no go. That's that, to me, is taking advantage of economic vulnerability.

Griffin Jones  46:13

Which your standards of course, are higher, which I think is good. By the way, Dan, I think that's ethical. That so because you could argue that's a form of economic coercion, like, is she really consenting to donate her eggs, if she absolutely has to feed her firstborn, or if she has to make rent or any number of things pay off a debt that's going to send her in a bankruptcy. And so you're you're checking for this and where I just can't believe that's the case in many of these other countries. And, and, and in many of these other countries, that the threat of what living to paycheck to paycheck actually means is greater than it is here. And I'm not saying it isn't, it isn't a big threat to live paycheck to paycheck here. But one, people do it more in other countries and to what it actually means is that you don't eat. Yeah, I lived in Bolivia, I lived in Bolivia in 2014 and 2015. And poverty in Bolivia means that you don't get you don't put food on the table that night. And and so if there aren't different social safety nets, and so simply by virtue of having donors from other countries, you simply couldn't have that same level of assurance of what we might call economic coercion, because they do have that economic threat. It is more present. And it's more dangerous. And generally speaking. 

Diana Thomas  47:52

Well, true. And I you know, I see your point, I think that sometimes I hear the argument that that we do it here in the US to the point is, I think that's a red herring and you hit it right on the head. The Social Network is here to rescue people who do fall into those pits. I mean, if she had no food, could she go to a homeless shelter? Could she? Are there leaves? You know, she educated she? Could she get another job? Does she have legal remedies for if she was abused here, or she felt she was coerced? It's so different. When people have support systems built into our social network, as you saying,

Griffin Jones  48:30

Yeah, I don't want to belabor the point. But I think a couple of people might listen to say, No, it is still bad here. And as it can be bad here at different points. I'm telling you, it's nothing like what it is in these other countries. I'm telling you, you're poor here means that there you're you're living in public housing, and it's rough and appliances aren't working. And sometimes utilities aren't working and, and there's there's lots of crime and all of those things are serious dangers. What poor means in Bolivia is that is a dirt floor with a tin roof. And you there is no there's no there's no public transit that you can even just get get a bus pass for there's no soup kitchens, there's no there's no homeless shelters, at least in the rural areas. And so, you know, this is the case and a lot of different points. So I won't I won't belabor that anymore, but I know somebody's probably thinking, Oh, no, it's still just is but I'm telling you, it isn't. And, and so Okay, so you've you've, you have these checks and balances in place. And thank goodness, no one has had to use the red dot but you're taking the women away to make sure that that they're not being trafficked. out what let's talk a little bit. We talked about what egg banks can do. We talked about what what, what you're doing. Let's maybe talk a little bit about what else clinics can be doing because and you alluded to this checklist, which I think people should go to your website To download, we will have it on the page for this episode, we will link to it in the email that we send the episode out into. And, and people should go because every CEO is going to want their team to look at this, every lab director is going to want to look at it every practice owner is going to want to look at it. But let's talk about more about what what happens to clinics if they don't have these things in place and and what they can do to protect themselves from using human traffic DAGs.

Diana Thomas  50:35

Well, you know, I suppose just not using them at all, it's really the only way to be safe. How to How can you say that this cohorts probably okay, but this cohort isn't? I don't think you can do that. I don't think it's a matter of protecting yourself from traffic degas's from third world countries or developing countries. You can't change the whole social system and other countries. So the only way you can stop it is by not supporting it by paying for the eggs. You know, there's the the the intendant parents have no clue this was going on, you imagine telling your child you know, an 18 year sorry, you know, your donor was a prostitute. And there's her Baba records were blown up. So I can't tell you anything about her. You know, I mean, it's just the down, you know, this is not going to just stop with transferring eggs, it's going to be the pregnancy. So children born, the children who want contact with the donor, as time goes on, I think that there'll be a lot of losses if people are not more careful about this, and just don't engage in it. The FDA is catching on. And you know, I think it's a disservice to our own clientele, I mean, our own profession and our own, the people that we really want to help that I know that every clinic and Doctor really wants to help. Because they can't they can't double check any of that stuff. And they should stop pretending that they can. I don't know if I answered that question or not. It's it's kind of just goes on and on. You can't. There's no way to do it halfway. I guess.

Griffin Jones  52:21

You really can't use eggs from these other countries you have to use those from that are where there's there's one source where it's one country, are there other countries beyond the US that you feel are safe. You mentioned that sometimes us Canadian citizens said the US Canada or their other countries were okay. If if donors are coming from these areas that then that safe? Is it only developing countries that you're concerned about?

Diana Thomas  52:50

Now? I mean, I think you can work for donors in Australia and the UK, but the chances of doing that are pretty low because of their own laws around reimbursements. I I don't have any trouble recruiting donors, I have more donors, you know, I can I have 200 that are already all banked I could I could double that in six months if I wanted to. So when people say that I you know, we've got to do this, there just aren't enough donors. I just have to disagree and see, you're doing it because you're making a ton of money easily. And you don't know how to recruit donors. You don't you don't put three or four staff people to do this 100% of the time, which is what it takes. It takes a lot of time and effort, especially to get it right, legally. And worldwide, which is what we do. We follow laws and at least six different countries. So everything has to be really marked.

Griffin Jones  53:47

Donor sources is one of the areas of the checklist that you also have, you also have an accountability in which you list out specifically what that means with CDC with us. It means where were they sent prior to us that also kind of dovetails with the with the part of the checklist that you have for chain of custody, where we're monitoring who maintains the chain of custody who's who's handling who's doing the auditing, then you have an area for patient care and practice liabilities, the risks that they've been informed of the family limits, and then you also have section for donor care, talking about how to know if the donor has been stimulated more than recommended, etc. Tell us about some of these these other areas and what practices should be concerned about?

Diana Thomas  54:40

Yeah, I think, you know, again, it's been documented everywhere in many places, including the dissertation that when a donor is hyper stem, she comes back to the clinic banging on the door and they say tough your donations over a good luck go find go get better somewhere. So they're not cared for any Any repetitive egg donation over, you know that many repetitive egg donations has long term consequences for these women, the clinics, you know, they're, they can't verify the records, they can't verify the profiles, they can't verify the ID, all they do those who have eggs sitting in front of them. And they feel that well with the patient went there and and ordered them, what am I going to do, I just have to warm them and transfer them. But the fact is, when a doctor takes eggs and warms them and fertilizes them, and puts them back in a patient, he saw last chance to rectify a problem that will that could happen to that woman and that child, he's participating, he's condoning the whole process, if he transfers those embryos into a patient, he, they're not going to go and sue a broker or a pimp in some other country, they're going to sue the doctor here in the lab and the staff. It's you know, so it's, there are huge liabilities, I think, and they just haven't, it's kind of shown up yet, because it hasn't been around as, as commonly as it is now, very long. So we'll see what happens in the next six months to a year. And if the FDA is already tracking down the Ukrainian eggs, they're gonna be asking people and clinics when they do their audits, to find out to show them the chain of custody. For the FDA testing.

Griffin Jones  56:29

I'm gonna give you the final thought I want to conclude with my final thought, because you're the expert in this area where I can shed some useful advice to those listening is that if this were connected to your clinic, and in something big happens, it can be one of those irredeemable public relations, travesties. So you're talking about the human concern, our listeners should be deeply concerned with the human concern, I'm sharing the business concern here. On top of that, the human concern comes first. But I'm sharing the business concern on top of that, that many of you are CEOs that are listening, and many of you are practice owners. But whether you're a practice owner of a six doc group in, in a city here, or whether you are the CEO of a network that is getting ready to be bought by another network, or to buy another network or to go public, imagine something like this coming out from the New York Times, that comes back to your clinic, this is something that you absolutely have to look into recommend you start by going and reading through the checklist, going to The World Egg and Sperm Bank site reaching out to Diana to find out more about this, but you absolutely have to look into it. Because if something like there was a an article that came out last year from the New York Times, they were surrogates, now they must raise children. And it talks about, you know, coercion, and human trafficking and surrogacy in Cambodia. But if an article like that comes out and links someone to your clinic, oh, and by the way, it was these clinics in the United States, these networks that purchased these types of eggs, that is a really bad thing to happen, especially if you're a mission driven organization, many of these fertility clinic networks, market themselves on the missions that they're building themselves toward, and that would betray any core values that, that they're open to build their, their brand. And upon and the the, I'm looking at the article that you talked about previously, Dinah, where it's police arrest members of a baby trafficking ring on Crete, Greece, if any of this is is linked back to your clinic, it's really bad. Again, the human concern comes first. But that's the business public relations concern. I strongly recommend everyone to go to your website and read this checklist. Again, we're gonna link to it in the show notes. We're gonna link to it on the show page, we're gonna link to it in the email that goes out it will be on The World Egg and Sperm Bank's website. And if you still need more help getting in touch with with Diana and finding those resources, I will I will connect you personally. But Diana, now, please. I want to leave it to you to conclude.

Diana Thomas  59:36

Well, I you know, I hate to be the bearer of bad news, but I'm actually really trying to partner with clinics to help them out. So they aren't in that situation with this education. But there's also another piece you know, the the US has ratified the UN Human Trafficking protocol. And in it there's also punishment that comes along with being arrested and convicted including repatriation of every Hanna you made from that Trafficking Act. So there is also a financial piece to this for networks, global networks I so I really hope people are listening. It's it's something we can reverse. I think we all love our patients who really want to take care of our patients and give them healthy babies. So we have to be aware of these things to move forward.

Griffin Jones  1:00:23

Thank you very much for coming on the podcast and and sharing light on this topic. I look forward to hearing more about the follow ups and about the people that reach out to you afterward. Thanks for coming on the inside reproductive health podcast.

Diana Thomas  1:00:38

Thanks for the opportunity.

Sponsor  1:00:40

This episode was made possible by our feature sponsor The World Egg and Sperm Bank, head over to www.theworldeggandspermbank.com/protect and download their free due diligence checklist to ensure that your program only sells eggs from donors that have been safely and ethically protected. That's theworldeggandspermbank.com/protect. Today's episode is paid content from our future sponsor who helps inside reproductive health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

196 Your Intro to The IVF Market in Latin America with Daniel Madero

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Daniel Madero, VP of Partnerships at LEVY Health, gives an inside look at the fertility industry throughout Latin America, breaking down the market from major players to major growth potential throughout the region.

Tune in to hear Daniel discuss:

  • The growth of the Latin American Fertility Market in the last 20 years [Revealing the countries that are major players by market shares]

  • Regional Regulations [And their impact on everything from taxes to gestational carriers for same-sex couples]

  • How Post-Covid Inflation is affecting the IVF-space throughout the region.

  • Why it costs 40% more to set-up the IVF lab in Latin America [As compared to the US and even the same country 10 years ago]


Dan Madero, LEVY Health LinkedIn

Transcript

Daniel Madero  00:00

It's a Greenfield, the amount of things that can be done in Latin America overall, just pick the country. You know, you have countries with populations of 20 million that are doing 2000 cycles, 3000 cycles, 50,000,000, 4,000 cycles, right? The conversation, I think should be, how can we get into Latin America. Straying away from the traditional model that we see in the US and Europe.

Sponsor  00:30

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients, please visit www.bundlfertility.com/medications-cost. That's bundlfertility.com/medications-cost. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.

Griffin Jones  01:21

This IVF market just keeps getting bigger, the number of people in the world that need IVF services is much greater than the number of people that are getting it now, that is much greater than any one given country. That's part of the reason why we've been covering so many different regions and players in different regions on Inside Reproductive Health recently, because you didn't see many national players 10 or 20 years ago, now you see plenty, and now we're starting to see those national players from different nations become global players. The region we zoomed in on today is Latin America, because from Mexico to the bottom of the South American continent lives in a population about double that of the United States. Yes, this is for the execs and doc's that aren't the most familiar with the Latin American market yet, but you practice owners, lab directors and executives in Latin America, I want your feedback. And I want you to share this with your audience. Because whenever I delve into a new region or new topic, I start broadly the more you ping me with you should have mentioned this dataset, you left out this player you left out this development, the more specific we make our content, the better it gets. If you want to see more content about Latin America, give me your feedback about this episode, and give it to my guest, Daniel Madero. Because I approached this topic broadly, I needed someone that seen a lot of different areas of both the industry and the clinic side in Latin America and globally, for some context as to how it compares. Daniel was the chief financial officer of a clinic in Colombia before it was acquired by Eugin than his general manager after the acquisition. He's been a consultant. He's led bizdev corporate partnerships, third party services in different areas of the quote industry side, and he takes us through the countries that have the biggest market share, starting with the top three, what their market share is how many IVF cycles they're doing, how many IVF cycles they're doing per million people how that compares to a country like the US or a really advanced IVF country like Israel. He talks to us about regulation, like same sex gestational carriers, or gestational carriers for same sex couples going through IVF. Now being allowed. And Daniel, welcome to Inside Reproductive Health.

Daniel Madero  03:22

Thank you, Griffin, it's a pleasure to be here with you.

Griffin Jones  03:25

You're going to take on a new geography today, one I haven't covered on the show before. So you're swimming into new waters, we've started to cover more of Europe, more of the UK, some of India, some of East Asia and Southeast Asia really have not even had one topic on Latin America. That is until today. And I think that it is beyond due time and want to delve into it partly because I think that we're going to see more of this consolidation, as you and I speak, there's a number of fertility networks that are for sale that are already cross continental, that may likely be purchased by other cross continental buyers, I suspect that we're going to see more of that. And so I just don't think it's going to be this backyard or that backyard in the future, even if globalization slows down for a while. So let's maybe start broadly with just what's going on in the IVF market and Latin America right now.

Daniel Madero  04:27

You know, say you had other Latin Americans in your podcast.

Griffin Jones  04:31

I have Latin Americans on the podcast, but I've never talked about that in America. No, no.

Daniel Madero  04:41

So overall Latin America is it's a special place. Because we have twice the population of the US are about 350 million, but only a fraction of IVF cycles. Within the space you're going to see that there are major players, we'll talk about it today, but the the rest of the continent is lagging behind. So we have Brazil, Argentina and Mexico, leading the way in that order. And then the rest of the continent is smaller on it. So in total, we're doing about 107,000 cycles, including egg freezing transfers, like fresh and frozen transfers, egg donation. So, you know, in total, and this is projected, so about 85% of IVF centers report into REDLARA, which is, you know, the equivalent of ASRM or x rayed for Latin America. And this 106,000 represent the the potential total, with those extra 50%.

Griffin Jones  05:57

So 100, so about 100,000, you're saying from all the way from Mexico, down to Chile and Argentina, we're talking about Mexico, Central America, South America got 100,000 cycles, maybe a little bit more coming from all of those countries? 

Daniel Madero  06:14

Correct

Griffin Jones  06:14

And that total population, you said is twice the the US so from all the way from Mexico down to the tip of South America, we're talking about 600 or so million?

Daniel Madero  06:24

Yeah. So we doubled the population, and we only do 1/3 of the cycles.

Griffin Jones  06:29

So are we seeing a really unequal distribution, you already said there is an unequal distribution, in that Brazil, Argentina, Mexico leading the way? And then and then it's a distant fourth from there is, is Brazil? Like, is their market? What's the market share chunks of those countries do you know?

Daniel Madero  06:48

So Brazil is gonna represent about 43% of cycles, followed by Argentina at 20% of cycles, and then Mexico at 15% of cycles. Everything else, you know, the fourth one is Peru at seven and a half percent. And Chile at 5%.

Griffin Jones  07:10

I'm not surprised by Brazil leading the way I am a little bit surprised that Mexico is a little bit further behind, because we're talking about I think, what is it 110 million? Are we talking about somewhere around 100 million in population, Mexico? And it seems to me like with the explosion of new tech industry, and a lot of reshoring, that's coming back to the US a lot of that manufacturing, coming to Mexico, is that part of the reason why you're seeing Texas just explode, you're in Austin, you part of the reason why you're seeing that area blow up is because you have the tech sphere in Austin, then you have the semi skilled manufacturing in Mexico with regard to that. That's how it's called in the channel. And so I would have thought that given what I perceived to be an explosion in their economy, that they would have been further ahead, are they? Are they catching up real fast? Is this 15% been stagnant? What what's it like if we zoom in on Mexico?


Daniel Madero  08:14

So we want to talk about Mexico, I think let's talk about now more challenges within like each one of these countries. And one of the things that is going to be ubiquitous across Latin America is the price of IVF cycles. They're extremely expensive compared to what a regular person will make. So what we end up with is that IVF cycle represents a higher percentage of their total income, thus becomes harder to attain, the prices tend to be on the higher end. So and, you know, bear in mind that there is a difference, a major difference between pricing the US and the rest of the world overall. So in Latin America, you could say that, for multiple cycles that are three cycles, you're going to end up spending $10,000 $11,000, depending on where you are, and that represents a really high percentage of the total income of the patient.

Griffin Jones  09:27

So if we're talking about three cycles going to add about 10, or 11,000, is that just to the clinic, or does that include meds? Typically, an estimate?

Daniel Madero  09:38

I'm gonna say that this depends on the country, but yes, it this will be meds included.

Griffin Jones  09:43

Okay. So all in we're talking about maybe 10 or 11,000, where that could be 50,000 in the US, but it's still we're still looking at something that is proportionate to income, out of a lot of people's range. Correct? What other challenges are Are our countries facing? So are they are they seeing from as far as you can tell the same shortage in embryologist and fertility specialists that we've seen in the US and Canada.

Daniel Madero  10:13

On the one hand, in Mexico, that is not a challenge just because all OB/GYNs in Mexico are trained with reproductive endocrinology as well. So any OB/GYN in Mexico can perform ART services. So in Mexico, doctors are not a challenge. What I have seen though, is that, embryologist, if they have good English, will often get exported. So they will be hired for by outside clinics. So from personal experience, I have a friend that after being in Colombia, he went to Dubai did a short stint there, and then came back to Colombia and is now in Cairo. perfect English, highly skilled. And of course, the salaries are gonna be a lot higher in dollars than they are in Colombian pesos or insert the currency

Griffin Jones  11:21

so lesson to all the lab directors listening don't teach your embryologist English, you're gonna lose them. So then are there operational challenges that you're seeing that are different than in the EU, I suspect it varies country to country, but are we typically seeing the same workflow where it's, you call you maybe get a referral, you come for your new patient visit, typically you do your testing between your new patient visit in your follow up some clinics, of course, do testing before new patient, but most I think are still doing it in between the patient and follow up, what's the operational system look like?

Daniel Madero  12:01

It will look very similar. You know, I'll give you a very specific example, in Colombia, a lot of the patients come from referrals. So a lot of the times the clinic's name will be very closely tied to the doctor's name. So the patients will come to the doctor referred to by a gynecologist. In other cases, you will have something that happens in Mexico, given that they can do their own cycles, instead of sending them to a clinic, they would rather keep them get them pregnant, and then keep that patient all the way through to delivery. So you're gonna see, you know, different dynamics, but for the most part, there is a referral system, it functions in the same way than in the US. So you have lower cycles per per doctor, you know, so we're not talking about doctors or clinics that are doing your 800 cycles per doctor. But on the, you know, on the 150, 200 cycles, 250 cycles per doctor, which is on the lower end.

Griffin Jones  13:15

Yeah, I would say it's on the lower end. And so you're saying that some clinics are practicing obstetrics that they're keeping those patients because that would change the referral pattern?

Daniel Madero  13:25

Yes, in Mexico, it does. And in Colombia used to be that case, and it's changed over time. I cannot speak to Brazil. And I know in Argentina, and you know, here we can talk more specifically about about dynamics in Argentina, IVF cycles are covered by, you know, healthcare. So that's one of the other reasons why you see such a high percentage of cycles being performed in Argentina, because they're just covered, unlike in Colombia, where we have a socialized health care system. So on average, when you go to the hospital here in Colombia, you'll pay maybe a couple bucks, when you're when you leave. But when you have to pay out of pocket, you just don't like to pay out of pocket, right? Like you don't pay out of pocket, because you're not used to it. So when you see a bill that's for, I was gonna say pesos, because it would be millions of pesos. You're not used to it, and you're a little more careful of your money in those cases, right? Healthcare is healthcare. So if you're used to going to a hospital not paying any money, when you get to a fertility clinic and you're charged, you know, $5,000, $10,000 then you're like, wait, wait, wait. I don't know if I if I want to do this. I don't know if they have the money to do this.

Griffin Jones  14:50

I want to come back to this question of coverage in a second. But on the on the obstetrics part I could see that disrupting, I could see that limiting some new patient growth because if, I'm going to go on an assumption is that the reason why they want to keep the patients for obstetrics is for volume and revenue, they don't have enough IVF volume, they make more revenue if they keep them from obstetrics. But that by definition means that there's some type of valuable revenue happening in obstetrics, which means that in a situation wouldn't want to lose that revenue. And so yeah, if you have a gynecologist, it's also practicing obstetrics, are the partners in their practice? Are we less likely to refer to that group? And I, that could be part of the reason why you see fertility clinics getting less referrals in Mexico, if in fact, that's happening?

Daniel Madero  15:44

Yeah, I would agree. I don't want to say that's the case. But I can see that definitely happening. I know that that was a dynamic here in Colombia, that has changed.

Griffin Jones  15:55

Why did it change in Colombia?

Daniel Madero  15:57

Because doctors stuck to just doing fertility. So the other doctors, their friends, would know, hey, this patient that can't get pregnant, instead of me trying to do you know, my seventh IUI, you're going to send it to Dr. X, Dr. Madero, and my dad, and my dad would return a pregnant patient. So it made more sense to just ship out everything that they couldn't do, and then get back a presentation, which is where the, which is the revenue they're looking for. Now, here's the other thing in Mexico, you have, you have doctors taking patients to labs. So that's another model that is common in Mexico, there is a clinic. And instead of having, you know, a set of doctors that are affiliated to that clinic, there are different doctors that bring their cases to the clinic. So say, you know, the clinic has Dr. X, and that Dr. X is doing 30% of all cycles that are being done at the lab, yet 70% of the cycles come from outside doctors that can bring their own patients. So that's another dynamic that you see in Mexico as well.

Sponsor  17:14

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Griffin Jones  18:02

So I wonder if it's a question of like just where the development phase in the market place is. And Columbia has reached that level of maturity and development where they now can have fertility specialists that only do fertility cases and, and so they don't, they're not practicing obstetrics. Is that on the, I know I'm asking you to speculate so maybe you can't, but is that on the horizon? From what you can tell in Mexico? Or do you think fertility specialists are gonna be practicing obstetrics for a while?

Daniel Madero  18:36

That is a really good question, but I cannot speculate on that, to be honest, I would get I would try to ask Paco, for example. He might, he might have a better idea on it.

Griffin Jones  18:46

And this is how I approach all of these topics. They start really broadly. And then the more I do, the more I'm able to zoom in and ask better questions in any one of these countries, particularly the top three could be there could be their own topic, and then you could have certain players in each of those three, that could be their own topic. So you mentioned my assumption would have been, and this is why we don't assume, but my assumption would have been I didn't conclude it that the entire Latin American IVF market was cash pay or almost 100%. But you said in Argentina, the government pays for cycles?

Daniel Madero  19:27

Yep. So I was reading the law this morning, actually. And I think it's if you're a woman that is looking to do IVF it will be covered with your own eggs up to 44. 

Griffin Jones  19:41

Two cycles, one cycle?

Daniel Madero  19:43

I don't have specific numbers to be honest.

Griffin Jones  19:45

So that would, because it did kind of surprise me, to see Argentina almost double what Mexico is in terms of their their share of the Latin American IVF market. Argentina is a smaller country by population, probably a higher per capita wealth, but it's still,

Daniel Madero  20:05

 In Mexico?

Griffin Jones  20:06

I mean, like the total, the total like so if you took the averages of, of Buenos Aires, but I would imagine, again now I'm really, I'm really be sticking my foot in my mouth and talking about what I what I don't know. Um, so it's just a guess but I would suspect that Mexico has a higher GDP total, but but in the per capita wealth is is higher in in Argentina would would be my guess. But so so they're they're paying for cycles on there. Are there other countries in Latin America where they're paying for IVF besides Argentina?

Daniel Madero  20:44

Yep Peru, oh well no, actually that IVF is covered you mean? 

Griffin Jones  20:48

Yes. 


Daniel Madero  20:50

I don't know, I don't know to what degree I know that here in Colombia there is a there's a push to try to get covered. Given that, you know, most of healthcare is socialized, why not IVF? Right? It's still a disease. Right. So there has been a push to try to get that through. And it's been really difficult. I don't know how it works in Brazil. I don't think it's covered. I think it's cash pay. The one that I'm sure of is Argentina. I would I would like to say Chile, but like looking at the numbers, maybe, maybe not, because Chile's is very small country anyways. So I wouldn't really know.

Griffin Jones  21:34

So what's happening with regard to people trying to scale IVF in these markets. So in the US, it's all about let's get from 250,000 into at least 2 million cycles. We need to be automating the lab, we need to be practicing at top of license, we need to be training more specialists and advanced practice providers. We need artificial intelligence for case management. And you have a lot of players and by players I mean, on the vendor side, these are the people that we see in booths at ESHRE and ASRM that are trying to break into the US market some with more success than others, are people trying to break into the Latin American market in the same way, like do they see it as an opportunity where well, if we can really drive the cost down, then then the markets even bigger or is the US the place where people generally want to try to do that because the margins are greater up front? And then then then if they can scale in the US that they'll be able to take some of those economies of scale to, to higher population, lower per capita income regions like the Indian subcontinent, Latin America.

Daniel Madero  22:51

So I'm gonna go on a small tangent that I think it's related to this. But if you think about all the different technology that we have in IVF, it's the same across the board, be it in India, China, Colombia, the US, what we have is same incubators, the same laminar flow cabins, you have, you know, state of the art labs, all of those are very expensive. And if you have a weak currency, setting up one of those labs, he's going to be way more expensive. So to give you an idea, when I set up a lab here, like a clinic here in Colombia, the price of all the equipment was put here in my lab, about 30% to 40%, more expensive than what it would have been in Spain, or in Europe or in the US. So that right there, it's an indication that there's something that's happening within that it's the media is more expensive. The petri dishes are more expensive, though, XYZ just put it in there, because most of it is made in dollars. So without these technologies that you're talking about, if they're going to be charging $500 a patient, then in a country like Argentina, that is now going to represent about, you know, 25% of the total cost of the cycle. So I don't think we're doing the same. I think that we've been looking at how things are being done in the US and Europe and basing it on that. And when you just transpose whatever it's being done elsewhere here, the prices are not going to change much. The other part is medication. Medications are extremely expensive. Nevertheless, they're not as expensive as in the US, right? Like, for example, this is a conversation I bumped into the other day with someone in the US and Menopur was considered the low cost option. Here in Colombia verses a Gonal-F, or Follistim. So when you think about that, now, you bring a completely new dimension into the equation, right medication ends up being a higher percentage of the total cost of the full cycle than what it would be elsewhere. All of that, because, you know, things are being brought in, in dollars. And when the dollar goes up, and the pestle goes down, that means that, you know, intrinsically IVF is going to get more expensive.

Griffin Jones  25:35

Has that happened in the last three years with inflation? So I, the only Latin American currency that I follow is the boliviano. And it hasn't changed it is, it's hooked to the US dollar, it's always around 6.9, sometimes you'll see it 6.8, something you might see it six point, it's always around 6.9, somewhere around there. And an even with the inflation that we've had post 2020 through 2022. And maybe even in now, it hasn't gone, it hasn't gone up, it hasn't changed. It's always hooked to whatever the US dollar does. Now, you can get a ton of variance in Latin America, especially in Argentina, where when I was living in Latin America, Argentina had 40% inflation year over year. And that wasn't like a COVID stimulus. That was like that was like the status quo. And so, so did did we see like an extra did this come into play more with the inflation that has happened globally, post COVID.

Daniel Madero  26:40

So I'll give you the the Colombian peso example. Before COVID, it was sitting at, let's call it, you know, $3.5 to $1, $3.5,000 to $1. By the end of last year, we were sitting at five, to $1. And now we are at four, for $1. So it's like playing jump rope 10 years ago, it used it was 1.82. So that has a huge incidence in, in the result, right? Because what ends up happening is when I set up the lab, 10 years ago, 12 years ago, the all the equipment costs have avoided what it would cost today to set up a ladder, because everything has to be imported. And now you want to talk about local regulation. Brazil is a complicated country, in terms of bringing in external technology, media, that it's a completely different story, when you want to bring in, for example, gametes, and all of these are going to be at a premium, if you will, just because of the currency exchange. So the challenges of bringing new technology in, for example, here in Colombia, you're going to pay? I think it's depends depending on the on the type of equipment between 20 and 40% taxes on the equipment.


Griffin Jones  28:11

And you're saying taxes as in like an as an import tax and tax not, you're not talking about the the lowercase t tax of inflation, you're talking about actual government taxes, 

Daniel Madero  28:24

Government taxes, correct,

Daniel Madero  28:26

Yes. It will depend on the country and it will vary. I know that Brazil is very, there tends to be heavy on on taxes for importing things. And it tends to favor locally made things here in Colombia it goes up and up and down. But it depends on the type of technology. I would say it's similar in Argentina. Also, you want to talk about politics, which I really don't want to talk about, but overall Latin America is leaning left at this stage. And when you have governments like leftist governments taking over, then there is a higher price on specific types of products and services as well. So you see those taxes going up. And as a company, if you're buying something that sales tax, you know, so you have the input tax plus the sales tax. So it just balloons to the point that you're going to be paying 40% more than what you would pay in the US.

Griffin Jones  28:26

in that 20 to 40%. I want to I want to talk about taxes, I want to talk about regulation, I should mention that what you're saying on the on the side of the jump rope of the Colombian peso, that that's just currency rate exchange, I'm not and when so when I say that the boliviano is attached to the dollar I should be making the caveat that that doesn't mean that there isn't inflation in Bolivia, there is, because the you know, the the purchase power of of a boliviano and the dollar has gone down. And so that's just currency rate exchange. So you can be getting it on multiple set you can be getting on the currency side, you can get it on the purchase power side. And then And then you mentioned taxes are due those really vary from country to country. Is that 20 to 40% pretty standard? Are there some that have really high taxes and then like Mexico being a NAFTA does that change? 

Griffin Jones  30:23

So before we talk about regulation, I want to see so it seems like just from a cost perspective of materials, media technology, at least hardware technology, I, I'm thinking HSGs, and things like that, it's it's going to be far more expensive because of the currency rate because of the taxes. What about these AI companies that are really trying to break into the US and Europe? Are they trying to break into Latin America? Or not really yet? They're trying to figure the US out first, and then and then they'll come to Latin America?


Daniel Madero  31:02

So I know that, you know, IVF 2.0, is based out of Mexico. So I'm guessing and hoping that they have partnerships in Mexico and are willing to spread that technology down into Latin America. I know that which one is it, Life Whisperer, is already available in a few countries in Latin America as well. And I don't know how the pricing structure works, but I'm guessing it's going to be a different pricing tier for a clinic in the US than a clinic or a patient in the US and a patient in Latin America. But to be honest, I don't know of other ones that are trying to get into the market. Now, if you think about the reasons why I'm gonna play, I'm gonna try to, you know, put myself in their shoes, you have 106,000 cycles, that are distributed to a pretty small, total percentage of the population with a high price sensitivity in very difficult, it's not like you get one certification, like CE mark in Europe, and you're everywhere. It's you have to go to Colombia, you have to go to Mexico and learn how to deal with Mexican system with the Colombian system with the Brazilian system, you know, insert Portuguese here, Argentina, Peru, Ecuador. And when you're talking about, you know, a couple of 1000, few 1000 cycles, the legwork might not justify coming into these markets.

Griffin Jones  32:42

So it could be a while before we start to see some major innovation happening, let's say in Bolivia, I don't know, there has to be a fertility clinic with an IVF lab and in Santa Cruz, Bolivia, I suspect that there, there's I suspect that there's one in Santa Cruz and there might be a one in the Paz and Cochabamba there's probably at least one in Santa Cruz.

Daniel Madero  33:05

There are three, there's three, they're doing in total 1000 cycles. 

Griffin Jones  33:09

Okay. So you got three clinics doing 1000,  look at you with the data. I asked Daniel to do some some homework, because I know he's good with this stuff. But I wanted him to be able to pull up a couple of those numbers that I don't know. Thank you for that. So three clinics doing 1000 cycles. So because of the reasons that you just mentioned, the variance in regulation, the variance, it's not like, it's not like you're you just get that CE sticker good for the whole EU, you get the FDA approval, you're good for 330 million people in the US, you you're going from country to country, and some of those countries are so small market, it could be a while before we really see, like a scale and innovation in a place like Bolivia?

Daniel Madero  33:49

I would say so, right? I think the focus is going to be on those markets that are bigger. Argentina, Brazil, Mexico to start with, and then trickle down into other ones. There are some ways to do homologation of certifications here in, in Colombia. So like, I know that the regulatory entity is a little more lax with devices that have gone through FDA approval already. So if you have FDA, it's easier to get into one of these markets. I don't know for other countries, but in the end, that could be the case if you have gotten through FTA then getting into one of these countries is going to be easier. I'm gonna guess on this, I'm not gonna guess anything actually. Rather not.

Griffin Jones  34:41

Well, then then talk to me about what's happening in Brazil as in as in what ways is Brazil an outlier to the rest of the region? Because it's one it's a larger country. It's got a higher GDP, higher per capita income and While none of not not a highest GDP, not a highest population, not as high as per capita income, anywhere close to the US, I could still see it having a lot of what these companies are attracted to in the US. And and that also might be more cash paid in the US is right now could be attractive to different people coming in tell me but in what ways is Brazil an outlier?

Daniel Madero  35:26

Let's start with your average middle class yearly salary. In Brazil, it's about $9,000. As I said, a year the average cost of an IVF cycle is $5,400. That's about 60%. It's pretty high. But if you look at the population of Brazil, there are a lot of people with a lot of money, I'm also going to guess that financial institutions are a little more advanced, does access to capital comes easier. It's also a country, the sheer size of the country. It's a market that big. It's, you know, a big opportunity, however you see it. And now we're talking about Brazil doing 50%, sorry, 50,000 cycles, how much does that represent? Like the total potential amount of cycles that could be done, it's just a fraction, right? With with a, with a population that big, we're seeing a very low penetration overall. So Brazil, to give you an idea, it's doing about 230 cycles, for every 1 million people in the country. In the USA, we're doing 800 for every 1 million people. And you know, the ideal, right, like, the place we want to get to is an Israel at 4300 cycles for every 1 million people. So I think there's still a lot of potential of growth. And like I mentioned before, just doing an IVF cycle is going to be 60% of your yearly salary. So just bringing those costs down, is going to really open up a big opportunity in any one of these countries that we're talking about. Now, what I know is that in big population areas, like Sao Paulo, you have mega clinics, by clinics that are doing 5000 cycles in you know, per year, which you know, challenges or like it goes head to head to those big mega centers that we have in the US, like big centers. So, we have those in Latin America, but there's still so much room for growth Majan, if you took that number of 230 cycles for every 1 million people in Brazil, and we're able to get to the 800 in that they have, we're talking now about 150,000 cycles being done in Brazil, unlike where they are today, which is like 50,000. So one of the major challenges and I think you know, you're talking about technology, one of the major challenges that we have here in Colombia, in Brazil and Argentina in Latin America overall, is how do we stop looking at the rest of the world? And how they are doing things? And how can we figure out a model that works for our own economies for our own populations, frameworks, like legal frameworks, how do we get to that? To give you an idea, Colombia is a country that has now regulation, it's great area regulation, but it's legal to do surrogacy, and same sex surrogacy as well. And it's become a destination now. There are there are clinics now they're just focusing on surrogacy here in Colombia. And that's a great thing, right? We are increasing the number of cycles we're doing. The caveat though, is that we are not offering services to our own population. So the need is still going on map. And if we find a way to change the way the process is being done, say like a Paco and positive, then now we are we're getting into the meaty, the good of how can we grow the market in Latin America. So I don't think that the opportunity lies in the traditional ROLAP which has been tried before. With IVI like either IVI came to Mexico. There's a history with IVI and Latin America. I don't personally know it. But it would be for example, a great thing to to research you But IVI, Eugin, so you know, the same group that's going up for sale that you put an article up on a few weeks ago, they are here. I was I was part of the first acquisition of Eugin outside of the nuclear clinic here in Colombia. And, you know, I'm not gonna say it's not going great. But it's still not growing the market significantly, like we should be doing. So I think the the key to success in Latin America is in how can we change process? Or how we can help? Can we create technology or develop technology that suits the needs of our populations? And I know that, by the way, like, I want to give thanks to, I'm advising a company here in Colombia, and they were the ones that provided a lot of the information that I'm giving to you right now. But they're working on increasing access, here in Colombia, right? Like, how can we take what we have here today, and we improve it, we change it, and we get to more people, instead of going to from sort of doing a recycle recycles for 100 million people in Colombia? How can we do 800 cycles for every one 1 million people in Colombia?

Griffin Jones  41:19

And so is when you're going through this, you can't make legislative changes, you can't remove taxes, but you might see some things as you're visiting clinics in these different countries that that you think, but they could do this? They could do this? What is what's the lowest hanging fruit that you see that if you if you ran? If you were the CEO of that clinic group, that that would be one way that you're able to do more volume?

Daniel Madero  41:50

That is such a good question. I would think it's the doctors, you know, REs, for the most part, doing most of the cycle. And they're the ones that have to do it all. I'm generalizing. I don't know if this is the case in most clinics, in all clinics, but I think there's an opportunity there to offload a lot of the work to the different parts of the of the clinic. On the other hand, it's precisely that right, if you're talking about going to a public hospital is how do you create a good referral flow for those patients in need of fertility treatments? Because sometimes, and I remember this from my conversations with OB/GYN here in Colombia, they would, you know, try time relations for eight months to a year with a 39, 40 year old woman. And at that stage, it's like, wait, you need more education, right? That's not That's not how it's supposed to be done. Or earlier at the eighth, ninth IUI, the patient would come to us and be like, well, I've done nine IUIs, what do I do now? Like, well, there are other options out there. So general education, both to doctors, patients, but also those creating those flows with her hospitals overall, or OB GYN groups, you know, insert however the country works to get those referrals earlier and faster.

Griffin Jones  43:32

You talked about some of the key players who are you talked about, you know, Eugin, which is a Spanish company and owns Boston IVF and they own Trio in Canada, and they're owned by Fresenius Helios right now, you talked about IVI which is merged with RMA to become IVI-RMA. IVI started in Spain and that RMA started in New Jersey, but who are like the who are the big networks there that, you know, like who's their equivalent to the inceptions preludes us fertility panic calls. And I guess I'm the like, maybe there's not as much of a difference between the MSO name and the clinic name. But like the Shady Grove Fertility, the Boston IV of the HRC, like, who are the really big groups that are in Latin America, and where are they?

Daniel Madero  44:20

Brazil? And okay, let's talk about groups because I don't think there is, or there are like big networks here. Other than the ones that are coming in from outside. So Eugin owns the biggest if not one of the biggest clinics in Brazil, Huntington's. you have the ones in Argentina, same. They own one of those in Argentina. So they've been buying the big ones, right, because that's where the profits will be.

Griffin Jones  44:49

You talked about networks coming in like IVI and Eugin, and those would be like the US Fertility's and the Inceptions, and the Pinnacles, and then who are they, who are they buying? Like who are the Shady Groves, the Boston IVFs, the HRCs, the the really, the Vios, the big groups that are in different areas that people are buying, like who are those big clinic names in different countries, or at least a couple of them?

Daniel Madero  45:20

In Argentina, we have CEGYR. And I know that they also have a lab of their own. So CEGYR, Huntington's in Brazil is a major one as well. So here being CEGYR, Dr. Sergio Papier, being the medical director there, you have Huntington's in Brazil, in Brazil, there are more than one, I'm just gonna give you one Brazil, Huntington's owned by Eugin. Now in Mexico, you have a group that's in finance, and I know they have more than one clinic across Mexico. There's one in in Peru, and they're the biggest by a good chunk by a margin called Concebir. They're in Lima, but they also have like clinics in Aliquippa and in other places. Here in Colombia, you have two big ones now one called Inser ,of the other one ReproTech written the same way as the cryo storage in the US, ReproTech, those would be the ones that I would focus on. Because the rest, I don't know that many clinics in other parts that are going to be as big, you know, on that scale. It's a Greenfield, the amount of things that can be done in Latin America overall, just pick the country. You know, you have countries with populations of 20 million that are doing 2000 cycles, 3000 cycles, 50,000,000, 4,000 cycles. Right, the conversation, I think should be how can we get into Latin America, straying away from the traditional model that we see in the US and Europe. And insert, Africa, any country in Africa, it's going to be very similar. You're seeing the sheer size of India makes it that it's an incredible market. But you're seeing it in India, you had a great series on it. But yeah, I think the opportunity in Latin America with 660 million people, or 650 million people projected to be like 750 by 2050. It's a massive opportunity that we shouldn't be overlooking.

Griffin Jones  47:45

And we'll be getting into more specific topics about Latin America and IVF market as it progresses. But I needed somebody to walk me through the one on one. So sorry, that didn't go too deep into any of the the the particular verticals that we could have, I will want to and want to have you back. And for some it may have been too elementary, but I think you got to start somewhere. And my questions that is we're we're too elementary for your scope. But I think that this market is going to be one of the ones that you see a lot of big growth in, whether it's whether it's next month or in a few years, I don't have a crystal ball, but it's time to get the one on one, one on one out of the way because you're gonna see more of it. And you are the guy to come on and do it. Daniel Madero, my friend, thank you very much for coming on Inside Reproductive Health podcast.

Daniel Madero  48:39

Thank you. It's a pleasure. It's all it's awesome to be on this side of the mic, and I can't wait to see what else you put out there.

Sponsor  48:47

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients, Please visit www.bundlfertility.com/medications-cost. That's bundlfertility.com/medications-cost. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guests appearance is not an endorsement of the advertiser. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

195 My Secrets For Selling to Fertility Doctors: Revealed


I share my secrets for having sold to over fifty fertility clinics in seven different countries despite having no outside funding or previous experience in the fertility field. 

Listen to Hear How To

  • Engage multiple decision makers at fertility networks

  • How to shorten the sales cycle to fertility clinics

  • How to pull in the chief decision makers like practice owners and CEOs when they kick you down to gatekeepers


Transcript

Griffin Jones  00:06

Do you sell to fertility doctors? How do you sell to fertility practice owners? How do you do this and a time when fertility practices are consolidating, when MSOs are participating in the channel conflict to get better deals, there are fewer buyers. When there's channel conflict on the player side, we have so many people trying to sell in to such a small percentage of people with me be 300 independently owned clinics in all of the US. and Canada, if there still are of that many there's only about 500 fertility clinics to begin with, and relatively proportionate numbers and other parts of the world. How do you sell to these folks, we're going to explore that today, fertility doctors and those of you that work in fertility clinics, I don't know if this episode is going to be interesting to you, maybe it will, you're kind of a bug on the wall, I suppose in this conversation. This is instruction to industry side companies, those businesses that are calling on you and I put industry in quotes, some people like the word some people don't. And I'm telling them how they can call on you and be more effective in their sales and marketing to you, you'll tell me if I'm totally off this episode is for them. But I hope you enjoy it too. So start off with what I think the problem is. And there are multiple problems, but you could distill it down to there is a divide between sales and marketing in the fertility field. In many businesses overall large and small, it's one of the things that you hear very often breaking down the barriers between sales and marketing, breaking down the silos between the two, it's very common in small companies to what it means is we need to connect sales and marketing marketing is just copy. It's just art, it's just promotion, if it doesn't actually connect to the sale, That's its job. And there is a bit of an under appreciation between the two. Sometimes marketing people see sales as a less noble approach to the same aim, that it's pushy, that it's not as creative. And sometimes sales view marketers is a bunch of artists and English majors that don't actually have to be accountable for a result, at their most cynical they can be right but what we want is for marketing to set up to sell. I'm not good at a lot of things in this life. But one thing that I have gotten really good at professionally, as I think that I've gotten really good at professionally is appreciating both that there has to be a bottom line result, a sale has to eventually come from your efforts. And that marketing can uniquely position you to be able to do that so that you're adding value to your prospects so that you have greater opportunity than you do have capacity. So you can walk away from lousy deal so you don't have to pressure people. So you can be that helpful resource that you want to be in the sales process. What does this disconnect look like in the fertility field? There's a lot of booths, there's a lot of sponsorships, maybe the webinars, you have brochures, you have newsletters, and sometimes those go out through marketing channels. Sometimes it's your sales people that are manning those different channels. But then it's very often disconnected from what the actual sales process is the prospecting, call your discovery call the sales download, follow up the sales meeting, the follow up the follow up. In fact, those names are so sales oriented, that is are very often is something missing in walking the prospect all the way through the process in a way that adds value to them, and puts you in a position where you're helpful where you can walk away and aren't just somebody trying to peddle something, of course it depends on what sub vertical you're in within the fertility field very often I asked you how did SRM God PCRs go? How did this particular event or that particular endeavor go? Very often responses? Well, you know these things, it's about showing up and about building the relationship. And those are good things. But that's still too fluid. For me, that's still too much of marketing being over here. And sales being over here and want marketing to set up the sale now want to have at least a good idea of how it's helping to do that. Not saying that you can quantify everything that is a mistake that many people demand of sales, you can't qualify and attribute everything. But we should be able to do better than that. So instead of having marketing over here, and here's all your marketing efforts, and here's all your sales efforts over here. I want to walk you through a process of linking these different phases together. This is the process that my companies use that I've used to sell 1000s of dollars in marketing services over the last few years and this has been from someone that came into the field with no money, no capital whatsoever, not just no venture capital, no private equity, not even a dime from a bank loan. No money coming in as a D student who had been a generalist Digital Marketer and have been able to sell millions of dollars in marketing services to a field that generally has not been interested in marketing services. My prospects fertility clinics have spent half a percent of gross revenue on marketing. And yet somehow we've been able to do this since because I've gone through this connection to marketing and sales. Let's think of these from your prospects point of view. From a fertility doctors point of view fertility practice owners point of view a CFO at an MSL, or CEO or CEO of a fertility network, you might have seen different funnels and different flywheels it's pretty similar. Let's start with indifference, they're indifferent to their problem, or at least they're indifferent to your solution. Then there's awareness where they become aware of their problem and acknowledge it, then there's consideration where they actually might start to talk to you and consider you as a solution or consider solutions period, then comes indecision. Indecision is that point in the sales process where every single person that's ever sold anything knows exactly what I'm talking to? will think about it. Oh, yeah, we're ready to go. And then you don't hear back from them. Oh, this is something that we really want to work on, we just have to talk about it was so and so. And that process, which sometimes when things are going really good happens right away, but very often takes weeks and months, not only does the indecision phase very often take several months, it can also become a graveyard where sales go to die, things that had been very promising conversations, end up becoming nothing if you can get past indecision, that's when you get to commitment a decision from the buyer. These five phases are when fertility doctors, fertility practice owners and execs are in when we're trying to get them to buy our product, when we're trying to get them to write to our pharmacy, we're trying to get them to write our drug, when we're trying to get them to use our carrier screening company or genetic testing company to buy our EMR to demo our new software. These are the five phases that they're but to be honest with you, I very often don't think of that this in terms of the phases that they're even though I will say, but to be honest with you, I very often don't even think of it in these phases that they're in from their end. Yes, I always believe in talking about the problem that your prospect is facing, not starting with the feature not starting that with what you do, we're all tempted to do that. See it all the gosh darn time, even though every sales and marketing book and every wisdom, piece of wisdom that has come out about sales and marketing wisely advises that we start with the prospects problem, we often skip that. And even knowing that I just often don't think of it in terms of where the prospect is, I think of it in terms of what I have to do. And it's a sequence of things that I have to do in order to get their attention and trust so that I can actually help them and actually provide value first, I'm going to attract them get their intention, then I'm going to engage them then I have to secure the conversation, the process the relationship. So it doesn't go into the graveyard to indecision, how they have to close the deal, actually get the person to sign something to a money for it, and then be able to deliver it to them. And I used to think of the nurturer and delight phase, just in that delivery form. There is some bit of nurture and delight that you want to do across all those days, you want to be nurturing and delighting a little bit while you're attracting them a little bit while you're engaging them a little bit while you're securing them a little bit while you're closing them to nurture and delight shouldn't just be saved for the delivery phase. In my view, I think it's best when it comes in the delivery phase, I'd much rather have a happy client than a happy prospect. I can't sleep when clients don't feel like they've gotten value. And I love it when you can get a prospect to buy at the lowest expectation for them. So that then you can exceed that expectation. So this is how fertility bridge has done it through inside reproductive health over the years to sell millions of dollars in client services to a very small niche with no outside budget, no fancy parties, hardly even any sponsorships. And one part time salesperson, wha who is also running a company, and this is all very visual. So if you want to see the visual, I will link it, you can download it, go to the show notes of this page, go to the email that you got this episode from or go to insidereproductivehealth.com/fertilityclinicsales, and then you can get an idea of what this actually looks like. So in order to attract the audience in order to get their attention, that's where the marketing series comes in. And even though the main problem that we're solving for today is connecting sales and marketing. That's our central theme. What's one of the problems that has come from the consolidation that's happening in the field, though, to be fair, I think it's there, even if you're selling to small, independently owned practices is that there's multiple decision makers, even in a small independently owned practice, you might have the physician you might have the physician spouse, you might have a practice manager that the physician really trusts and relies on On, if you're selling lab solutions, you might still have to talk to their lab director. If you're selling lab solutions in general, very often you need the lab director to buy in. But they can't totally say yes, or write a check without having a senior partner, physician or the managing partner. If it's a multi physician group, they have different decision makers involved of their senior partners, some of whom are very involved, some of whom are less involved, some of them make decisions on committees, if it's an MSO, you'll very often have a chief medical officer, maybe a chief scientific officer, maybe there are some junior partners that you need to come and advocate for you. There's a CFO, a CE, O N, sometimes other different relevant C positions beyond the CEO. So that's where you'll see different articles and podcast episodes coming out from me that target lots of different types of folks. We'll talk about IVF conversion, branding, reputation management, we'll talk about things that my company itself doesn't even help with mergers and acquisitions, operational improvements, physician recruitment, because that's engaging the different decision makers, we're getting lab directors here, we're getting CEOs here, we're getting ce o 's there, and then we're putting in different messages at different times to let people know about our services. But that way, when I do get invited to a sales conversation, it's more likely that the person's partner has heard of me that the executives have heard of me, and they've heard of me and my company in different places, a podcast episode here and article here, any book here. So I have different nurture pieces for each of these different types of decision makers. And this is what advertisers who advertise on inside reproductive health do the same thing. We just help them make their nurture pieces and put it in their different places, to the different decision makers that we reach. But the advertisers just like us can't jump all the way to the sales offer. Well, they can and sometimes they'll get lucky. But it's not the most trusted way of fluidly going through the process. Well, it makes more sense in our second phase to engage the prospective fertility practice owner or the prospective fertility Exec is to give them a marketing hook something of value. A great marketing hook is something that really talks about your prospects problem and gives them the insight and data that they probably can't get elsewhere or would be hard to get elsewhere without talking about your solution. Talking about your features. A couple of really great examples of marketing hooks that we've had that have been really successful. We ranked every fertility clinic based on our online reputation. And then we gave that ranking to people to be able to see where they were we did the same thing. With brand, we ranked every fertility clinic on a four point brand scale. And people wanted to see that we gave them the criteria for the scale. So fertility practices, got to see interesting information, things that they wanted to know without having to hear anything about our sales message. And they got that for free. The more generous you can be here, the better off you can be. This is what we counsel advertisers who advertise on the inside reproductive health to do and some are better than others. Some tried to jump too far, the marketing offer that they have isn't that generous. The information isn't that competitive. It's not that detailed, and so less people are interested. Another example of a really good one was psycho clarity. And I can share this because Dr. Shore has given me permission to use them as a testimonial and a case study very graciously. They were also very gracious and generous in their marketing offer. They gave averages for physician time averages for physician salary for ultrasound Time for Nursing time for time spent on ultrasound, and they were willing to give that away in exchange for some contact information. But without any thing about cycle clarity about all the great stuff that they do. It was just in trusting and valuable information that they were willing to parkways in exchange for building that next step of the relationship with the prospect.

To get an idea for how your company might be able to get multiple fertility companies as leads, you can get a visual of the process at insidereproductivehealth.com/fertilityclinicsales, that's a free visual that shows you what the process looks like when it's broken, shows you all of the points of the process when it works. That's insidereproductivehealth.com/fertilityclinicsales or you can just email me Griffin, griffin@fertilitybridge.com or insidereproductivehealth.com/fertilityclinicsales. Now back to enjoying your episode.

So now we're in our third phase. We have nurtured them to our marketing series one, we have got them on with our marketing OIC, which maybe I'll change to marketing bait, and nobody likes to think of themselves as a fish. I'm happy to be a fish as long as everybody's transparent with our interests. They people don't like that. But I think it's a valuable way of thinking about this and maybe I'll change it to marketing data because I've got marketing hook onto sales hook but you need something to grab on to at least time so I might keep the word up and you may be dispense with the fish analogy altogether, because really, it's just about latching on, it's about getting traction. First is the nurturing pieces that happen through the marketing series, then we're getting them we're latching on with a marketing hook that is valuable and generous to the prospect. And then the sales hook is really where we want to latch marketing on to sales, we want to bridge this gap, we want to successfully pass off the baton without having to get them so fully committed into the sales process. Without wasting the prospects time without wasting your time. If we don't know if it's a good fit, now there hasn't been that qualification. And that happens with your sales hook. Your sales hook should be low commitment to yourselves into the prospect and it's gotta be valuable to the prospect, it has to be more relevant than Hey, do you want to talk on the phone for 20 minutes and see how we can help you even if it is actually a 20 minute conversation, give you an example number the marketing hooks I was talking about the one of the examples I had was we ranked all of the clinics on brand that was the marketing hook, you had to download that you had to give your information, say this is something I'm interested in. And then the sales hook after that was a saw that you downloaded this ranking Do you want to see the criteria to I can walk you through it. So it's relevant, it's valuable to the prospect because they've already been interested in the ranking. And you're putting a constraint around it that you're not just going to take up all of their time or your time. That's one example of a sales hook. Another example is, for example, what we just talked about this visual that if you go to insidereproductivehealth.com/fertilityclinicsales, or if you download this from the email, or if you download it from the page that this particular podcast episode is on, that's a marketing hook, you're getting this visual, and then I can reach out to you if I if we haven't talked already, or if I think might be a good time to have a conversation and say, Hey, do you want to see the rest of these examples? Do you want to have a 20 minute conversation, and we'll go over this and I will show you the different points of exactly how we use each of these five different phases so that you can see for yourself in a perfect world, we'd go right from the sales hook to the sales offer. But we usually need a sales nurture series. First, this is really where the sales comes in. This is really where people often don't like to get their hands dirty. Everybody wishes you could just put an ad up someplace and then all of a sudden you get 10 calls in the prospect as their wallet out and they just want to buy your genetic testing offering you want to buy your new AI solution, they want to sign up for your software they want to demo your EMR usually doesn't happen like that, we have to continue to build the relationship provide value. But there are ways we can do that more systemically where we waste a lot less of the prospects time where we waste a lot less of your time. So when you see the visual, you'll see the sales nurture series in between the sales hub, phase three and the sales off for Phase Five. But really, I like to use it as like a phase two and a half and a phase one out, I like to use it between the marketing and the sales up to so what I like to do is get the sales conversation scheduled. But then I'd like to send the prospects some information before we even meet those sales nurture pieces that come even before the sales hook that first sales conversation should have to do with the prospects most frequently asked questions. And very often the most common objections want to send that to them ahead of time to show them that you've thought about this before. And if there are any deal breakers, that they should cancel the meeting, you're not trying to get them in a meeting, you're not trying to squeeze them into something, you want to show them that you've thought about a lot of their questions ahead of time that you're ready, you want to show them that you don't want to waste their time you want to give that to them so that they can cancel if there is a deal breaker and example of one of those sales nurture pieces for us that I use between the marketing hook and the sales hook is we have a very extensive FAQ page probably need to update it. There's a lot of stuff for especially inside reproductive health advertiser prospects that I don't have on there, but on the client services, and Marguerite said is really robust it as most of any questions they could possibly ask and says, you know, here's what the deal breakers would be if this is important to you, we're not going to be a good set. If this is important to you, we might be and it links to a lot of information about our sales and our delivered process. I like to get that to people before I have that sales hook conversation with them, because then they can cancel if they want. And very often that meeting just goes much more smoothly, because we're both prepared. But let's say we're in the sales nurture series, where it really is the fourth phase it is coming between the sales hook and the sales offer. This is where you want to do some objection busting. And very often your sales nurture pieces can also be marketing pieces, the marketing nurture pieces, and just like in the marketing series, where you're creating different nurturing pieces for each of the types of decision makers. You do the same thing with sales, nurture pieces, you have different pieces that can speak to the objections of different decision makers. And this is where you can really smash that sales cycle, the length of that sales cycle and that's where a sale Sales Person proves their value, you can resurrect some of the potential conversations that were in the graveyard, you can crank down that 910 1112 month sales cycle to a few more months at a time, you can take some of those few months sales cycles and have a couple more of those unicorns that just go through real quickly. This is where you want to really meet the fertility doctor, the practice owner, the exact where they're at and bring them value with the objections that they have for implementing your software writing to your pharmacy, writing for your drug, adopting your EMR, trying out your AI product, because they're so effing busy, they have so much going on, there are a whole bunch of good reasons, believe it or not, for them, not even try your product, much less to buy it. I know you wouldn't believe it if I told you but despite having done business with dozens of Fertility Centers, we still have not done business with the majority of them. Can you believe it the best marketer and salesperson on the face of the earth, oh, my goodness, it's because they're busy, they have things going out, there are good reasons for them, not to try my product or service, let alone work, spend money and work with us. And that's the case for you too. So we want to address their objections with well thought out pieces, so that it isn't just you responding to an objection in a conversation, you can send it to them before the objection comes up. They want to read, watch or listen to it, because it's valuable. And when it does come up in conversation, you can reference it. And it's more valuable than you just bring up a point because you want to get a sale, it's something that you clearly establish a valuable point of view on a couple more examples for you for this is for the sales nurture series, two of the biggest objections that a client services firm can get, at least if it's in marketing is we already have a marketing team, we already have a marketing director, or if you're a client services firm, you often need buy in from the top that is more than just the vertical that you're helping with. In other words, if it's marketing, you need buy in from the top because there's going to be operations, things that involve the outcome that they're ultimately in search of, if you sell some kind of accounting, it isn't just the financial department that you might need help with it might be from the sales department as well the way that they send invoices and, and do other things and bring people on to their sales process. And so we have those two different objections. The first is we already have marketing team, we have a marketing director, that's a really big one. The other one is that there are different decision makers and many of them want to kick it down to someone else they want to step out of that process, we have to solve for each of those things, I have a piece called should I fire my Fertility Centers marketing director, now it doesn't say you should fire your Fertility Centers marketing director, that wouldn't be valuable. It instead, it very lays out the different roles for Fertility Center for Fertility company that they could actually use for evaluation, what those different roles do, what levels of responsibility they can be expect to have, what outcomes can and should be assigned to them, and then what support each of them need in order to achieve those outcomes. It's a valuable piece, we send it to people. And then people can see how we can help them in different ways. Instead of shutting out we have them we have a marketing director, we have a marketing team, which could mean anything, they could have a physician liaison, they could have an in house ad agency, it could mean a number of different things. And they can see oh, this is how they might be able to help not because we're saying this is what we do. But because it's very valuable for them to be able to see the different functions, the different outcomes, and what each role needs in order to be able to achieve those outcomes. On the decision maker side, I have something called the 12 point spectrum. And I give this to CEOs I give this to practice owners and I show them here are the areas where you don't need to be involved. And here are the areas where you absolutely need to be involved. And here are the points where the handoff comes. And I give this to them because we don't want them getting sucked into things that they should be able to delegate that they have to be able to get off their plate so that they don't have to micromanage and to show them. Even if you have a chief marketing officer, there are still some things that only the visionary and the integrator are responsible for. And these are the sales and marketing roles that cannot be delegated beyond the number one person in the company and here are the other roles that can be and we show them that 12 Point spectrum. It's valuable to them. We share this with them. If I run into the objection in the conversations, I sent it to them beforehand. And those two things are really important from stopping sales conversations from going to the graveyard to get you out of indecision infinitum. And to move on to what the sales offer is there can be multiple sales offers, but I break it off into something digestible and this is something that I tried to get our advertisers to do as well try to advise them and workshop with them on how to do this Because very often our solutions are a lot, there are a lot for Fertility Center to adopt or to even think about want me to implement this software with all of my nurses, you know what that's going to do to our whole billing process? How much work is this going to take for my staff. So if you can break off a piece of what you sell, that will help you sell other bigger things potentially in the future, but at least give you something that the prospect has to part ways with money for that they can actually become a client in take them away from the prospect phase and into the client phase in a way that is valuable to build a working relationships. And now you're not just somebody calling on them, but you're actually doing business together, and in a way that doesn't have them create a huge commitment or have to make a huge commitment. It doesn't put you on the hook if they're not a good fit, and it must be valuable, whether they buy anything from you after that or not. It's a big piece. Think of what our prospects do themselves. Think of what fertility clinics do, do, you just walk into a fertility clinic as a doctor and have three cycles want a gestational carrier, you're gonna write this amount of Clomid by the way, go ahead and throw in a couple of donor gametes and some Miksi in there first, they do a console, they do a workup they go over the results, they give a follow up, some people might in could be disappointed if that doesn't go on to IVF it has to be valuable outside of just the potential of it leaving to IVF the best fertility doctors and practices know this and do this. And fertility patients all over the world appreciate those that do when you can give someone answers when you can give someone guidance when you can give them value for parting ways with a little bit of money $300, somewhere between 306 $100, right, and hopefully it leads to the next step, whatever that may be, but it has to be valuable. Either way, almost all of you can do this in some way. This is where we help people work shop and get creative within it takes a little bit of time, it takes a little bit to get good at our sales offer. Another example for you is the gold diagnostic. You've probably heard me talk about the gold diagnostic on the podcast before dozens of fertility clinics have done it some industry side companies have done it to maybe 10 industry side companies have done but it's four or five something dozen clinics that have done it up to this point. And it took a little while to make sure that it was really valuable. But now I know that's going to be valuable virtually every time that people that we engage with to do the goal diagnostic love that they learn a ton and only about half of them do we go on to do more business with and I set that up from the very beginning. Just like a consults, it makes it easy for the prospect to say yes to as long as you've done all of these other things. It qualifies prospects further and it leaves them with a valuable experience. You'll convert more folks, yes, but even the folks that you don't convert will leave saying you know what, you should talk to those folks, they got something there, they have a good experience. Yes, it takes a while to figure out we can help you figure out it took us a little while to figure out but guess what, when you're starting at something so small, you can make the value up if for some reason you fail, I always started off charging $600 for the goal diagnostic. And if I couldn't deliver value, somehow I could find a way to make that up before moving to the next phase. That might be the last point on the sales offer, as it should be called something that is worth buying, as opposed to discovery call demo, things of that nature. We call it the goal diagnostic because we turn it into a deliverable. They get something from it and you can do the same thing. I hope this has been helpful to you. There's a temptation very often to say doctors aren't business people are these people coming in to the fertility field, they might have MBAs and have worked in private equity backed groups, but they have no idea what they're doing and the fertility field. Those are all tempting things to say, as a great salesperson or as an aspiring great salesperson, I always want to put the onus back on myself, it's always my responsibility to provide value, never the prospects responsibility to just perceive my value, always, always have to get better always have to provide more value. Always, always always. And with that, I hope you can repair this disconnect. It doesn't just exist in the fertility field. It's in almost every facet of business where you have a silo of marketing here, you have a silo of sales here now just doing a sponsorship or a booth or creating a newsletter or making a brochure, you aren't just having a discovery call a prospecting call over here. That becomes a process that fluidly links sales and marketing where the fertility practice owner is that the indifference awareness consideration and decision commitment, and you're doing that attracting them, engaging him securing them closing now all while nurturing and delighting the entire time by giving them a nurturing piece, a marketing hook latching on to a sales hook, using your sales nurture series to get them out of decision, indecision hell in order to move things along in order to provide value, instead of arguing about objections and to have a sales offer then makes it easy for them to buy and for you to begin to become a relationship that isn't just prospect but his client and that allows you to add more value and continue to repeat this process. For those of you on the industry side I hope this was valuable to you again you can get the visual in the notes in the email that this episode came in by going to insidereproductivehealth.com/fertilityclinicsales, fertility Doc's and practice owners if you did the last through all of this episode, I hope that it was valuable to you I hope that it gets more value to you from the people that are calling on you if you found this episode valuable where you tell me where you email me and tell me I love hearing. I love hearing when that happens. And if you didn't find it valuable, will you just shout it into a pillow quietly in your house when nobody's around. Never tell anybody about how bad it was. I hope so. I hope you enjoyed this episode of Inside reproductive health and I hope it gave you something to add more value for you for your companies and for the fertility practices, fertility, Doc's and fertility companies that you call on.



Sponsor  31:09

You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com to begin the first piece of the fertility marketing system, The Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.

194 Digitalizing, not digitizing, fertility treatment end-to-end featuring Dr. Cristina Hickman

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Embie has calculated 23 metrics for REI and clinic benchmarks for converting IVF Patients and we are making them available to you.

These metrics include; 

  • Conversion Rate from Referral to REI Consult 

  • Avg REI Appt Time for NP/ 1st Consult, Incl Prep and Notes

  • Avg REI Appt Time for F-U Appointments, Incl Prep and Notes

  • Total Appointment Time Per Year, Per REI

  • IVF Cycle Cancellation Rate

See the numbers for these metrics and 18 others to see how your clinic compares.


Cristina Hickman LinkedIn
Ovom Care LinkedIn
Avenues LinkedIn
Fairtility LinkedIn

Transcript

Dr. Cristina Hickman  00:00

If you want to think about the presence in the presence is the data is being captured automatically. So I'm using an electronic witnessing system, which is capturing the time that I started at the end of the procedure just by performing the procedure. So the doctor comes into his collection, he taps in his his cards onto the pump, the pump automatically knows that this particular doctor likes this particular brand of needle and preferably a single lumen needle, it automatically changes the pressure to match that single lumen needle. And now documents every time this doctor is pressing on the pedal to pump is documenting every tube that's being filled, and so on. This is now live recording of the data. It's not something that he did when he left it's recording as it's happening. So as a consequence of this, we can get live KPIs live and continuous KPIs.

Sponsor  00:53

This episode was brought to you by Embie. To see where your time is going visit embieclinic.com/report. That's embieclinic.com/report. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.

Griffin Jones  01:31

250 fertility clinics. How many clinics have you visited? That's how many today's guest has visited. Dr. Christina Hickman is an embryologist by trade. She has her PhD in embryology. She's the co founder and co owner of a clinic in central London called Aria, Aria? I don't know how to pronounce it. I didn't ask her how to pronounce it because she's involved in so many different companies and has been in the last several years, some that she's founded. Somewhere, she's served as Chief Scientific Officer or Chief Clinical Officer and somewhere she may serve as an advisor. And I like that background for really thinking about what the digitalization of fertility treatment looks like. Dr. Hickman makes the distinction between digitalization and digitization and a lot of you better listen closely because you're going to think your digitalizing but you're really just digitizing. So pay attention. She talks about the difference in digitalization versus digitization and everything from consents to prescription ordering and beyond including smart lab equipment, smart clinical equipment. I pressed her on, well, who's going to be the hub for all this because everybody wants to be the hub. Dr. Hickman proposes an alternative to the hub. She says there doesn't have to be a hub. Take a listen to that argument. Tell me if you think it holds water. I ask her why come we don't talk about blockchain no mo. Is it still a thing? Dr. Hickman talks about the route that the field took instead of blockchain and why she paints a picture of how the physical environment of the clinic and lab can merge with the digital environment so that it's one environment I liken it to a not Oscar worthy but better than airplane worthy movie from like 10 years ago that you can add to your watch list. You're welcome. Dr. Hickman paints a different picture than only vertical integration where one or three companies own everything, and she sees how community of different companies in different verticals can successfully integrate in an ecosystem and she shares some players that she thinks are doing really well in this area. Enjoy this conversation with Dr. Christina Hickman. Dr. Hickman. Christina, welcome to the Inside Reproductive Health podcast.

Dr. Cristina Hickman  03:29

Thank you very much for the invite. It's a pleasure to be here.

Griffin Jones  03:32

You were recommended to me by a few people, some which was the team at Embie but then some others. Everyone described you as forward thinking. So I thought that was interesting. I went to your LinkedIn profile. And then I saw a lot of X date to present, X date to present, X date to present. You got a lot going on right now. Tell us what are you up to?

Dr. Cristina Hickman  03:56

Yeah, so I'm a clinical embryologist. I've been a clinical embryologist for 20 years. And you know, as a lab manager, I have experienced myself as well as through my team, a lot of the challenges associated with providing care to patients. So I stepped out of the lab manager for brief periods where I traveled the world and visited 250 clinics around the world. And I did that through consultancy, supported by industry. So this allowed me to get a completely different perspective of how reproductive care is offered outside of the UK. So I got some insights into the US into Asia into you know, China and Japan as well as Australia and South America. And it was very interesting to see that the challenges that I was experiencing in my clinics in the UK, were very similar to the challenges in all the corners of the world. So from that point, I ended up joining some venture capital back to startups. This was my like tomorrow or fertility opportunity And each of these, we're trying to solve a part of the fertility journey. Together these, each of these companies kind of when you bring them together, you can now have the entire journey of the patient being able to be resolved. So the challenges we were experiencing were too big for a single company to resolve them. And this is why I'm involved with so many different companies, because each of them are the number one provider that supports that particular solution to a problem that I was experiencing for caring for my patients.

Griffin Jones  05:33

You mentioned that the challenges were surprisingly similar from what you were familiar with in the UK, when you would go to East Asia, Latin America, the United States, Australia, all corners of the globe. What were those challenges specifically?

Dr. Cristina Hickman  05:48

So for instance, doing consents of patients, right? So we historically we would do it with paper. So in the UK, we have a lot of consents that we have to go through which are regulatory required, we also have our own clinic consents to get through, and, you know, going, they're very complicated for the patients. So there have been digital solutions that have come into the market, you know, trying to provide you with PDFs, that our have made our life a lot easier. But the problem is that these consent platforms, although they are maybe integrated with your EMR as any deposits that PDF into your EMR, it's still like a separate digital solution to the rest of your digital ecosystem in your in your clinic. So one of the things that we've been working on is how can we get away from PDFs, you know, so PDFs is what we call digitization. But what we want to do is move towards digitalization, you know, those two extra letters, the A and the L provide a whole different leap into into efficiencies in the clinic, but also a different experience to the patients. So no longer do we have to deal with the patient having to complete the same consent three or four times, because he got one box incorrect. And therefore they have to do the whole form again. So we don't have to do, those inconveniences are automatically eliminated. And further to that, by taking away the PDF, you now you get a phone friendly version, because our patients are on their phones and not on a computer, they're on a phone. So now we can make it easier for them to to understand what it is there consenting for through convenience. And thirdly, because we're not in a PDF that's siloed. On the side, all this information now becomes business intelligence, because it's interconnected in the rest of your ecosystem, each individual fields that the patient has completed is part of the information that helps us better understand this patient. Now you take that just from consensus, or you evolve it now to every step of the process, every ultrasound scan you perform on the patient, you have that information directly from the source, every every time that a patient has an embryo on the embryos cultured in a time lapse incubator, that information, all of that is capturing that data automatically. And moreover, none of this is being captured by our staff spending time inputting information into the system. It's information that comes from the source of the information without administration. So the administrative tasks are completely removed. That's one of many examples, you know, that we could go through but every step of the journey that a patient is going through, there's a pain point for the patient and a pain point for the staff that's trying to support the health care of that patient.

Griffin Jones  08:34

So major difference between the two letters between digitalization in digitization, digitization, does that still include a DocuSign is just digitization because you're simply taking your existing consent, you have it in Docusign. And then staying on the example of consent at a platform level or at a software back end level. What does digitalization of that same consent look like? If it's not a PDF? That's being stored in a DocuSign signed via something like a DocuSign? What would the digitalization of that same consent look like?

Dr. Cristina Hickman  09:12

Let's say you're trying to fill in your your PDF form through your phone, you're gonna have to zoom in with your finger and you drag left and right you know, just to read the full sentence. But here everything is portrayed in fitting your your your your phone view, you're you're easily able to move from one page to the other, and your your your signatures and consents are connected with what you're permitted to do. You can enter if so, for instance, in the UK, historically, you couldn't put more than 10 years, you know, for for your consent period, or maybe your consent periods that you're putting for the storage of your embryos or eggs and storage is not aligned with your partners. Or you know, some clinics like to align it with with with their with their own conditions within their clinic. So all these things, you can provide a tool that educates the patient as they're going through, but not necessarily by them watching a video in advance, receiving the in the informational videos at the time they need it. But let's say this is not a visual patient, this patient doesn't like to learn through videos, because videos is not for everyone and she prefers to read, you can now choose the different forums of learning or educating yourself about the various decisions that you have to do throughout your treatment. And it's not just consents, you know, you can use this for instance, for embryo development. So you're able to see your embryo developing live as it's happening inside the time lapse incubator inside the clinic. So the patient is sitting at home. And they have that transparency of care to be able to see what the embryologist sees as well.

Griffin Jones  10:51

So Can these still exist as separate platforms? Is that even the right way to think of it in this move towards digitalization as opposed to digitization? I can't be the engage in engaged MD does it have to be an over encompassing EMR? It's you know, it's it's the it has to be the EMR in every function of the clinic and lab.

Dr. Cristina Hickman  11:14

So the challenge that we have with EMRs is that there's multiple reasons where I opted for building an EMR free clinic. So I need more for one thing is designed for a somewhere for you to put your information in there. Okay, so I've performed the procedure. And then I go in there, and I type in that I've started a procedure 8:00am, I finished at 8:30. And Christina did it together with Griffin who did the egg collection. Okay, so we, we've I spent, I did the procedure, and then I went out there and I documented that procedure. That's what an EMR is kind of designed for. And if I want to know about my KPIs, I will once a month, I will extract all the data, assuming that is an EMR that allows you to extract data, because not all of them do. I'll extract all the data, create my graphs, and then present this in a KPI meeting. Okay, so this is the old fashioned way of performing your, you're doing things from the past, okay? Now, if you want to think about the presence in the presence is the data is being captured automatically. So I'm using an electronic witnessing system, which is capturing the time that I started at the end of the procedure just by performing the procedure. So the doctor comes into his collection, he taps in his his cards onto the pump, the pump automatically knows that this particular doctor likes this particular brand of needle and preferably a single lumen needle, it automatically changes the pressure to match that single lumen needle. And now documents every time this doctor is pressing on the pedal to pump is documenting every tube that's being filled, and so on. The doctor just comes in performs the procedure and leaves only needs to document if there's anything out of the ordinary that that takes place. Otherwise, the documentation was just from him tapping his card onto the electronic witnessing system that includes the pump. So this is now live recording of the data. It's not something that he did when he left, it's recording as it's happening. So as a consequence of this, we can get live KPIs, live and continuous KPIs. So the moment that I put an embryo in a time lapse incubator, the AI comes in and automatically tells you when that egg has fertilized when it's degenerated when it's formed the blastocyst when it formed, the good quality blastocysts what was the pace of development, what was the score it was given. And all of these are automatic and continuous KPIs that allow us to monitor how our lab is performing a so we're now moving like beyond digitalization, where we're going now kind of towards a future where we're not just getting the data present. But we're getting the data for the future, we're getting it to predict and prevent what might happen next. So that we can take action before any non conformities have a chance to directly impact your success rates.

Griffin Jones  14:11

So are all of these different areas, whether it's the smart reporting from the electronic witnessing system, or the equipment ordering, or the informed consent, or all of these different tables within one master platform or these different platforms that somehow have to be integrated together?

Dr. Cristina Hickman  14:32

So a lot of when you're talking with the different companies, you know that the hardest thing to get this done is not the technological aspect, the technological aspect of integrating the different platforms is very easy. The issue is every company wants to be the hub or the central, you know, and and getting the negotiation of who's going to be the brain of the system is what makes it really hard to get the companies to collaborate with each other. Unfortunately, we are in a field which is run by humans. Humans are thinking on what's in it for me, right? If I want to collaborate with you, I want to get us to a point where we're thinking as a field, what's in it for the patients, if we really want to practice patient centered care, we need to be strategizing what's best for the patient, across companies, across clinics, and working in a in a way that creates this community of digital experiences that feels like a single one. And this is what we are creating. So the the two companies that that we built, one is called Avenues, which is clinic in the UK. And the other one is called Ovum Care, which is a new German entity, which is going to be opening the first clinic in Portugal later this year. These are now two companies that are coming together, to create together with Embie, and with many other digital suppliers, this, this neutral experience, where as a community, we can bring the digital tools together synergize without a single entity, a single hub, you know, nobody is the brain of the system. We're just interconnecting all of the solutions, so that they all get the best out for the patients to experience the best possible care. So it's a different form of thinking rather than going in what's in it for me, we're thinking that's now wipe out the all the options strategize with all these chess pieces we have available. How do we get it? What's best for the patient?

Griffin Jones  16:27

Am I understanding correctly, that there's an alternative to the hub? Because when you say everybody wants to be the hub, they sure do. And so to their venture capitalists and their private equity partners, and there's a whole lot of money at stake in in them being the hub. And many people do have the patient's interests at heart, but they're not going to say to their competitor or their potential competitors, as their vertical start to overlap. Oh, no, we all want the patient to be number one here. So why don't you go ahead and be the it's not a Canadian standoff with after you, you go ahead and be the, the the hub everybody, they want to be the hub, they've got a real vested interest in being that and so you're sitting? Well, you so you're saying it's possible to have a workaround to a hub?

Dr. Cristina Hickman  17:16

Yes, so there. So this is exactly what we've built. So we, in our clinic using Embie, using Fertility, using TMRW, okay, so all of these different companies and their we are able to solve, none of these companies are offering a solution that goes across the entire span, okay, but they are the best at what they do. If I want to store an embryo that was my personal embryo, I want that stored in a TMRW's robot, if I were to better understand how my embryos developing to get better strategies for my care, I want this to be assessed by a fertility AI tool. So what we do is we, through the care provision, we have a digital strategy of how we're going to approach this. And what we're what we have is now companies are willing to have these integrations across across the platform, what we what that's going to create as a next step is the ones who are outside the community ecosystem will wane away, okay, because they won't be relevant anymore. If you're not part of this digital pathway, then you're not going to if you're if you're, and I see a lot of EMRs being in that category, if you refuse to integrate, or if you charge too much to integrate, make it too expensive, which that expense will be passed on to the patient, then the companies will find alternative routes, which which which make it more relevant to the patient.

Griffin Jones  18:40

So I was going to ask about the EMRs, because many of them aren't in the digital pathway, or they'll say, sure, we'll integrate, but you're gonna pay us a good chunk for integrating. And we're the hub. It's, it's it's our data. And so we've been saying this for a while that the walled gardens will eventually, the walls of the walled gardens will come down, those that keep their walls up will be rendered irrelevant. It hasn't happened yet. So what is, what are we waiting for? Why are these companies that are not in the digital pathway, it seems like they still have a lot, if they have a number of fertility groups, large fertility groups, they've got their data, they're entrenched with them, it's very hard to switch EMRs. It seems to me that it could be a long time, to me it seems like the only thing that would get them out is those big legacy clients not renewing and switching out. And that's a long sales cycle. It seems to me like the only thing it would be switching out is is there any catalysts that would come forth to make those EMRs that aren't in the digital pathway render them irrelevant more quickly? 

Dr. Cristina Hickman  19:55

Like there's a lot of clinics out there who you know, you go to a website and it says I am the lead in clinic, okay, or I offer a state of the art, okay? If you're if you're sending a stash of papers home with the patients and getting them to do the consents through paper, if you're if you don't have time lapse system, if you're not using electronic witnessing, if you're not creating a centralized data infrastructure so that you're having live and continuous KPIs, if you're not using AI for your assessments, whether it's for ultrasounds, whether it's for, then you're not state of the art. Okay, and I think that's, that's a big statement. And the same goes for the patients, if you're being treated by a clinic that gives you that experience, you are not being treated by a leading state of the art clinic. So I think it is the catalyst is going to come from two levels. One is the patient's noticing, because now there's going to be the alternative to go to the clinics that are using these technologies and are open to digitization. And who are who really are putting the work in to do that transition away from EMRs. I mean, we still have clinics out there that are completely paper based, okay, there's there's, there's some which are, you know, really far back, they need to move away from the paper, move towards the digitization, and start strategizing. How do I get to be better informed? How do I get better business intelligence, so that I can adapt to this changing world that we're going to be facing now in this in this next generation. So I'm here today to tell you that this is not talking about the future. There's nothing that I'm telling you today that is not available in the markets today. So there's no reason why we should be doing paper prescriptions, you know, we it should be electronic, there is no reason why we shouldn't be integrating with a wearable detail from the patient so we can better understand their how their behaviors are contributing towards a fertility success. So this, we've reached a new era, where now we're going to see the ones who are able to adapt to it. And then the clinics who won't, I think are gradually going to start disappearing.

Sponsor  22:04

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Griffin Jones  23:12

For those EMRs that have been the walled gardens thus far, and I'm not picking on them. I understand they've got costs, they've built their businesses, they're trying to think of the future value of their companies and they're trying to win their races. For those that have been walled gardens, is it too late for them? Is it too late for them to go the route of entering the digital pathway?

Dr. Cristina Hickman  23:38

No, definitely not. But the strategy needs to change. So I think COVID, of all the bad things that COVID brought to us, the one thing it did that did very well was it created this this we've evolved 30 years in a space of two years when it comes to digitization in healthcare. Okay, and this is something that has allowed us to evolve away from that siloed What's In It For Me concepts to now the company is already thinking what are the strategic partnerships that we need to be making, so that we can provide better service to our clients who can then provide better care to the to the patience. So this, this philosophy is already there? I think we're going to be involved evolving to the next level up where we're going to be seeing not just one or two interconnections, but how do we how do we maintain our strategic positioning within this ecosystem? So we've gone through a process where everything was siloed, this has all been dismantled. Now, people are trying to find their place in this digital world. And those that adapt will continue to have this community approach. And this is what I think is different that it's not just about technology, it's about frame of mind. It's about a curiosity towards evolving into the next position. How do you position it? It's having this realization of What are the strengths that you as an individual you as a company bring to the to the fertility care world. So many examples out there of big groups of clinics who have spent half a million, a million building their own EMR systems or building their own digital AI digital solutions, only to be third grade or fourth generation below what is the standard of care from from companies that focused on just that one thing. So I do believe that the future of our field is going to be a community of companies working together as opposed to one big company only acquiring or the smaller ones. And then there's mantling it and then figuring out how they grow in an artificial manner. So I think we have a new opportunity here to grow a different aspect of our care.

Griffin Jones  25:51

Interesting, because I just recorded an interview with Lou Villalba, new the new CEO of TMRW, and we made that topic about vertical integration and some vertical integration is going to be inevitable, you're painting a picture where it's not where not everything is vertically integrated, where you have a community, and there still is a value in having separate companies doing what they do best. And not just one company owning every piece of the value chain. There's so people should listen to both episodes, because they're both they both paint different things that will happen in the future. 

Dr. Cristina Hickman  26:26

I mean, what what what is different about the digital world and the digital technologies is the fact that the world moves very fast there, and things become obsolete very quickly. And therefore you need to have a very creative and innovative culture environment to be able to survive in that space. And this is why I do think there will always be space with smaller companies to kind of find find are treading because of the nature of the fast pace of digitization.

Griffin Jones  26:54

And the tension between innovation and efficiency. There's a book called The Innovators Dilemma, theory called The Innovators Dilemma, I've talked about it on the podcast a couple of times, and the incumbents often are disincentivizing from, are disincentivized from innovating, because they're trying to win the efficiency game. And you sure you a really good company will carve out a piece of budget time leadership focus to focus on future value. But inevitably, that tension is something that weighs on incumbents, and there's a space for new companies to win the innovation game. I want to jump on the digitalization versus digitization examples in other spaces within the space some more because I know that my some of my audience is not getting it there. They think they got it but they don't. And the example that you gave about the paper prescriptions, people will say, Oh no, no, we fill prescriptions, we just do that through the EMR or we do it through the pharmacies portal. We don't use paper, we use those but that's still digitization isn't it versus digitalization of having of having that that data in a place where it becomes business intelligence?

Dr. Cristina Hickman  28:11

Okay, so So let me explain the digitalization in terms of prescription. Okay, so how prescription is done in the past will be you, you put in the patient's history again. And then from that, you you create, maybe you have a template with so let's say you put in I want I want an antagonist cycle, I'll go with a low dose for this patient. And then you just kind of tweak what is the what you want. And then that generates an electronic hopefully, in many clinics are still paper and they still got assigned by ink. But let's say that generates an electronic. And then from that electronic concerns, the patient is able to take it over. In digitalization, we go a few steps further. So for instance, when you create all of these, the history of the patient, so So this is what I'm going to prescribe this patient, she's going to have an antagonist cycle, I want her to have the following egg options and sperm options and genetic options and so on when and she's going to be using donor eggs, or she's going to donor sperm or whatever, and you press enter, it then creates a template of all the appointments that this patient is going to have. So she's going, I'm a particular doctor that, I might prefer to have daily scans or maybe I just do two scans in a cycle, they maybe I'll do a baseline or maybe a day nine. So you kind of put in this is my template in terms of cycles. And from that you already get all the tasks that go to your your team members. For instance, I selected she's going to use donor sperm. So therefore all the donor sperm matching tasks get sent to the relevant team members. So all of these tasks are there, you can tweak it. So you have all the appointments and all the tasks are there. And with the click of a button, it then goes on to the prescription. And at this point you're not signing. What you're doing it is you're confirming it, and then you get a two step authentication onto your phone confirms that this was you because that's even safer than then signature nowadays. And then it gets sent over directly to the pharmacy so that this gets delivered maybe to the patient's home or with the ability to. So whilst you're doing this, that's it, the patient has a copy in their patients app, and the patients can see that prescription. And all you had to do was two clicks, one to confirm the appointments and the or under tasks going to the team members. And a second one to confirm the drugs. The prescription side, it goes a step further where you can use AI to suggest what would be the based on the BMI, based on the age, based on all the other patient demographics, and not just your template, but now using patients and tele data intelligence so that we can do true evidence based prescription. Okay, so this is digitalization. And then when you start thinking about prevention, and so on, let's say as you're doing your scans either side to up their their adults, it can automatically calculate saying, look, for this particular patient, she's only purchased or she was only prescribed a set amount of drugs, now that you increase your dosage, we need to make sure she's got enough stock. So it's preventing the patient running out of drugs before you even realize that she's going to run out of drugs. Okay, so this is the difference between digitization and digitalization.

Griffin Jones  31:24

So, we have proposed an alternative to the hub and that these different companies are capable of these business intelligence, they're capable of this automation, but when it overlaps, who does, who does the data go to like if it's if if donor sperm tasks are triggered by by something, maybe maybe a pharma order or something that happens in the clinic from smart hardware, then the next step when when the steps overlap? Who owns those business insights in a world where there isn't a hub? How does that, how is that workflow managed?

Dr. Cristina Hickman  32:07

I'll give you an example on the genetic side, for instance, okay, so I am doing an egg collection. And I know that this patient is going to be having egta. So the moment that I put the embryo in the time lapse incubator, the genetic lab can now see as early as like the second day of development, what is the chance of there being blastocyst for this particular patient. So the genetic lab is part of the care provision team. And it's already been allocated that this patient is going to this genetic lab. But now the genetic lab can see not just in this particular patient, but all the patients coming from that clinic, all the patients coming from all the clinics that are associated with this lab, they can see how many blastocyst am I going to be getting in the next three days, they can tell that in advance, which means they can now make a determination when's the right time that I should be putting my 96? Well, this for analysis, should I wait one more day, should I bring it down a day, because whether you're using the full 96 wells, or whether you're only running one patient is going to be the same cost. So you can better strategize, and therefore, just by having that insight of how the embryos are doing on the second day, and by the way, all of this happened without any human spending their time sending an email of I'm expected to send you blastocysts in three days time, all of that is completely unnecessary, because of this information. Now, the who holds what information and how that information flows, is determined through the regulations and the contracts between the different service providers. Okay, so for instance, in Europe, we have to comply with GDPR. So the patient's needs to be fully aware of who's handling your data, how is it being handled, and as an hfpa licensed clinic, it is our responsibility to ensure that everybody is being responsible with that data. So we have checklists that we go with each of the suppliers to make sure that they're complying with the quality of data handling that we expect them to be to be having.

Griffin Jones  34:04

How does the blockchain back all interface with this or or these platforms built on the blockchain?

Dr. Cristina Hickman  34:12

So at the moment, the particular projects are working on the moment, none of them are using blockchain. I have worked in blockchain before I came into the field through Apricity. So we did a collaboration with Okin, who is a specialist in blockchain. And we actually built a blockchain specifically for research so that we could bring data from different parts of the world. At the time, I was doing a lot of collaborations with China, a lot of collaborations with Russia, with Japan with the US. And each of these countries have very strict rules about data not leaving their particular country, especially healthcare data. So the blockchain is a fantastic solution, allowing the algorithms to learn in the different hubs without having to, without the data having to move. So what moves are the algorithms, not the hubs. So the technology exists politically, I wasn't able to get to that project to succeed. But the technology exists in allowing that that that to to work. But this was because the no money was involved. We're trying to do a and again, this, this reflects the whole What's In It For Me siloed data, this would be a project that would make perfect sense in a patient centric community. But when I was working on this five years ago, I think we just weren't ready for it, then.

Griffin Jones  35:30

Are we going to see more of the blockchain as the spine behind a lot of these platforms? Or is there a way of doing this without the blockchain over a sustained period of time? Because we seemed like we were only going to talk about the blockchain for about four and a half seconds. And then we started talking about AI. And we haven't talked about blockchain since though is is blockchain still an inevitability or now are there ways where we think that it's these types of platforms will exist for a meaningful period of time without it. 

Dr. Cristina Hickman  36:05

So I tried to blockchain wrote, and for those who are willing to do the collaborations, they preferred to do it by protecting the data integrity through contracts and through regulation, and through through cybersecurity. So there are alternatives to blockchain, which is what's the field opted for even today, so not not just at the time, but even today, so the technology is there. But there are alternative ways of doing it using logic using legislation using legal contracts. And I'm in full compliance with the with the multiple regulation, it just means that we're not moving huge hubs of data. This is data being transitioned through care provision in a safe and secure manner. So for instance, Europe has, in their list of places they don't want their data to go to, is the US is one of the top places where if you're sending data to the US, because of the regulations around data handling in the US being different to those in the in, in Europe, it's one of the places they say, if you're going to do this, you need to ensure the safety of the data. So what we can do is create cloud environments which are in the US, but which are fully compliant with European standards geographically in the US, but they're not interconnected. They can they can, they can demonstrate its security accordingly. Okay. And on top of that, if you're going to be doing that we have to inform the patient, that we're going to be moving data to the US. So this is effectively contractual ways of kind of resolving that challenge.

Griffin Jones  37:38

How did you find yourself moving so far down the clinical end of the spectrum of the solutions, like by the time you get to consent, you know, it's for things that are done in the lab, but it's happening in the clinic, your background is, as an embryologist, how did you end up going beyond just lab solutions to broader clinic solutions?

Dr. Cristina Hickman  37:58

Mostly because I started owning clinics. So now I start looking at the clinic as a whole as opposed to just a lab. But also because my initial focus was on embryology based solutions. But I quickly became aware that so for instance, when I'm labeling my data, which embryos become a baby in which embryos don't become a baby, I now have the issue of Wait a minute. Was it a good embryo? It just happened to go to the wrong uterus? Or was it a good embryo that just happens to have a doctor that made a mistake during the transfer procedure. And so this is called mislabeling where, actually, the AI did get it right. But other things outside that data form. Because I'm only looking at the time lapse information, I'm only looking at the embryo, I am missing the rest of the fertility care. So my interest started spawning, actually in both directions post transfer and pre transfer. So we've done a lot of work on for instance, how we make stimulation decisions, how do we determine the type of trigger? How do we decide the right protocol for this patient, and so on. And what I discovered when I went into that, because it was around COVID times that I started getting to simulation, everybody had moved on to antagonists. And I started to appreciate how little diversity we actually have in the clinical side, compared to the embryology side, there's a lot less options to choose from a lot less opportunities. But when you think about it, that's not because there's less options is because the technology for data capture wasn't there. So now we have AI solutions that tap into your ultrasound and capture a wealth of data in the same way that you have AI solutions and embryology capturing a wealth of data from the timelapse. So I think we're going to be seeing a lot more focus on the clinical side as well. Because on the embryology side, it's all about not making any mistakes. Once I get my eggs and my sperm, it's all about do no harm and try to not you know, as long as I keep them safe, they will hopefully have the viability that they were there seems to have it's all opportunities for error rather than ways to improve the egg. Whilst in the clinical side we have the opportunity to improve the egg, we have the opportunity to improve the quality of the sperm. And I kind of saw the pre embryology side as an opportunity of not just mitigating the risks, but actually increasing chances of success to patients.

Griffin Jones  40:24

Are you still fertilizing eggs you own clinics, you're involved in multiple ventures or starting ventures you're also the adviser to other ventures? Are you still in the lab fertilizing eggs?

Dr. Cristina Hickman  40:35

That's my that's my safe space. That's my that there's no better place than sitting down doing an exit doing a biopsy, doing a vitrification, you know so, so very much. Embryology is kind of like playing an instrument and you kind of need to keep playing it or you're going to lose your touch. So I have obviously I don't do it in the same volume that I did before. But I'm very much involved. I do workshops where I'm training embryologists as well on all these skills, but certainly yes, performing the procedures as well.

Griffin Jones  41:04

Just to keep this saw sharp. So sometimes you're going to be in the lab with a junior embryologist. And here you are owning the company and you're involved in all these other companies and there's some junior embryologist just out of university is their first real job and so that happens sometimes?

Dr. Cristina Hickman  41:20

No, definitely. I think there's many examples of embryologists who have gone out there to create they're out there to own their own clinics to wonder that they will actually to I saw today David Sable put an article in Forbes talking about how clinics should be owned by embryologists, which made me chuckle because obviously today being World Embryology Day, I thought that was quite quite timely. So I certainly think that we are seeing an era of empowerment of embryologist, whether it is because they own their own clinics because they are venturing into the the corporate space and I would really encourage many embryologist to go through this journey. For me it was it was a very insightful, both in terms of my own personality, my own characters and understanding myself, but also in acquiring new skills. So you know, now I'm involved in running, I'm running FDA trials together with fertility in the US, I am understanding how to how to get CE marking and FDA approval of products. I and this, you know, initially people say that you're venturing into the dark side, I have found it a very bright side into the corporate world. But obviously I never did a complete jump. I've always stayed clinical, I've always kept my hands on the clinical side. And I think this is kind of what has given me kind of a role in the field of creating communities, creating interconnection and creating a better understanding between both the corporate and clinical sides.

Griffin Jones  42:44

Well, being still in the clinic, is there a way that you see of balancing the physical space? Are there other changes that need to come with the physical space, not just the technologies being digitalized? But are there other ways that balance the physical space in the digital space? So there's sort of feels like one single environment?

Dr. Cristina Hickman  43:05

Yeah, so this is something that has been a big focus for us and ovum care. So when you're thinking about the branding, the marketing and the feel that your brand brings to the clinic, to not just the clinical but but to the to the patient to herself. It needs to feel like both the tech, the digital and the physical feel like one, there needs to be a consistency in your story in your look and feel. I think one of the things before as an embryologist, I never quite got the UX, UI and the look and feel. And I have a much greater appreciation now of how important that is to the patient and to their experience that they're going through. So what you want in your patient app is you want to have that ease that when you come in, you have all the information you have the transparency of your care, you have your own digital passport that follows you beyond the point in your journey where your care is complete, but you can always look back and it's they're accessible to you. There isn't a restriction on you accessing your own data, which is not just a legal requirement, I find it should be the ethical approach as well. But then you get that same feel when you walk into the clinic, where you have you walk in. So the way we've designed it, we didn't go the spa route. I found the spa route was too sedentary. I didn't want to go the big corporate route. It wasn't about walking in and feeling like Oh, I better dress up to come into this clinic. You know, so this has been some of the clinics I've done in the past. And when I did focus groups with patients, they said look, this place is beautiful. It looks like a five star hotel. But it's it, I don't feel comfortable in here, which kind of shocked us because you know, we had used the most expensive interior designer for this room. And turns out this is not what patients wanted. What a patient wants is to walk into a clinic and it feels like home. Okay, it looks and feel feels like they are in their own home. So for us, this meant that we use a lot of wood in the, in the decoration, we use a lot of a lot of texture. And we made the room, we have books around the place, we have lots of lots of plants, lots of trees, lots of making things look as natural as you can, and as far away from clinical and hospital feel as you possibly can get it. And definitely not going down the spa route. Because that's too relaxed, you want to get it to the point where they just feel comfortable in that environment. And this will reflect into their care. I didn't understand early on in my career, how important the space was, you know, so for instance, initially, the clinics I worked in had one office for the embryology team, one office for the nursing team and another one for the doctors. And this creates kind of competition between the teams, which is the opposite of what do you want to achieve. So open plan spaces, so similar to We Work offices. And do you have We Work in the US?

Griffin Jones  46:02

Did they go out of business? They were something happened with them? They were not. But yeah, they were they were a big rise. And then I think they weren't profitable for a while, maybe they're still around. But yes, we have them.

Dr. Cristina Hickman  46:14

But the idea is creating a space that's comfortable to work in. So what is the optimal environment that will allow me to achieve the best possible care to the to the patient? What is the type of ultrasound machine any to use the type of beds that the patient needs to be on? How do I hide the clinical field, and when I need to be compliant in terms of cleanliness, you know, for my CQC inspections, so there is we have spent a lot of efforts trying to find that right balance between feeling homely, not not feeling overly posh and feeling comfortable, yet compliance with healthcare requirements. And the way that we've approached this is by creating modular systems that will allow for clinic builds to be built up faster and therefore reducing the cost of care even further.

Griffin Jones  47:04

So as you started to talk more about the ultrasound machines that made sense of how that aesthetic translates to the digitalization in bridging the to the digital and the physical environment, but is that aesthetic that you chose? Is it a deliberate juxtaposition? Because otherwise the the digitalization just feels like you're in 2001 A Space Odyssey like I think of the movie Her? Did you ever watch that movie? 

Dr. Cristina Hickman  47:30

Yes, yes, it did. Yeah. 

Griffin Jones  47:32

For the audience that hasn't seen it, Jude Law, romance movie about he falls in love with artificial intelligence, it's really good. And one of the things that I enjoyed about the movie, it takes place in the semi near future, the undefined future where there's more advanced artificial intelligence. And in most movies where they do that, the aesthetic looks very futuristic. And they they counter position that with an older aesthetic, so it actually looked like the late 60s, early 70s in a in a kind of way, or at least that was that was marbled then throughout, and it it gave more credibility to the story in some ways, but it also made the aesthetic more realistic. Because it's not like I'm just in this like future pod like The Matrix, it felt like a proper balance.

Dr. Cristina Hickman  48:23

Yeah, and I think that's what, at Ovum our our tagline is where compassion meets technology, you know, and everybody associates technology with being cold. And I'm here to say that, you know, it doesn't have to be it's only cold if you use it in a cold manner. So how can we use technology to bring warmth to care. So for instance, whenever we're using the, our platform, we don't call the patient to tell them an update or fertilization we can face like, it's equivalent to FaceTime but directly inside the app through the security of the app. So we're able to see each other's face to face. And especially when you're giving bad news, you and you can read each other's face, and the patient can see the support from the facial expressions that you're giving to them. It's not just the tone of our voice, they can they can see us there, they have that option. And that provides that extra warmth, even though we're not physically together, you know, this, so so that approach of using technology to bring compassionate care has been also a big focus and has generated a lot of discussion of creating, for instance, different forms of communication that the patients can use. No more emails, okay, so everything. You can have email, like communications through the application. You can have WhatsApp like communications through the application. And the benefit and the nurses will love this is that at the end of sending the email, you don't need to then upload your email into your EMR. You just send it and it gets received by the patient. And now we have AI learning all the words that are being sent back and forth with the patients to try and identify things that we need to improve on. You know, do you have, are they complaining about there not being enough appointments available? If we start picking that up before the patient even gets a chance to realize as a negative. You know, there's, we try to fulfill that there's a Japanese feel words called Omotenashi. Do you know it? 

Griffin Jones  50:18

Nope. 

Dr. Cristina Hickman  50:19

It's about predicting what you're going to need before you realize you need it yourself. Okay, so what we are really using this as a true example of how technology can support compassion at a level where we can provide a care before the patient realizes their needs. By this point, it's already been fulfilled. And it's no longer a need.

Griffin Jones  50:41

Talk to me then in anticipating needs, how much is this technology? How much is artificial intelligence going to or should be, maybe not just treating infertility but maintaining reproductive health? And what's the difference in your view?

Dr. Cristina Hickman  50:59

Yeah, so I think that's a really important change in direction that we're going to be seeing, it's not there yet. We're seeing some early signs of it, but it's not quite there yet. So we are making that a core at both Ovum and Avenues. So in Ovum Care, it's not just about treating the infertility. So historically, we've seen infertility as a disease, we've made big points of getting the World Health Organization to recognize infertility as a disease. But I want to see if we can change that a bit. We're in a world now where we know our patterns of our sleep. Because of our wearables, we know we get beeped when we've been sitting too long. So go go take a walk, we know how many steps we've taken today, and what we've eaten today. So we're now at a stage where we know more about our bodies and our health than we've ever done before. Historically, what we associated with healthcare was going to a hospital, our children are going to associate healthcare with their smart ring or their smartwatch. Okay, so the perception of what healthcare is, is different. And because we are gaining a better understanding with tools that are available at home, we are we are have this expectation that we don't want to wait to be sick before we get treated, we want to see how we prevent the sickness and for infertility, that means not treating the patient when they have been trying for six months or 12 months, and then bring them into the clinic. I mean, can you imagine trying for 12 months and every month getting the, maybe next month, maybe next month, and trying again, and not being able to be treated by your National Health Service, because you don't fit the criteria, because you haven't been trying for 12 months. I mean, that's quite, quite tough. I had the blessing that I mean, I'm Brazilian, I had private care in Brazil. And as a consequence, I went to the gynecologist as a teenager, I understood my body from the age of 15. And I knew all my reproductive health issues early on, I planned my life. I had my children when I was 24 in my mid 20s, and I wouldn't have had I not known what was my reproductive situation. So in having this early in life, you go in, you understand your body, both the man and the woman, by the way, not just the woman, we understand, and we can do the appropriate plans. For me, the plan was just trying having babies early or earlier in life than I had originally anticipated. For others, this might mean freezing their eggs, or for others, it might be just coming to terms with the fact that okay, maybe babies are not for me. And this is something that if I ever want them, I'll go down the adoption route. But I know this early in my life, and therefore I can prevent the needs that I would have needed IVF I would have needed egg donation if I hadn't gone through that journey. So how many other patients right now are doing egg donation. And unfortunately, I don't have a time machine to give them to go back in time to tell them to change their reproductive plan. So this is the approach that we that we're taking, where we're not just treating infertile patients. We are combining infertility care with gynecology care with urological care. And we want to kind of see all of this throughout your lifespan even beyond in your menopause and andropause years so that we can have a better reproductive health not disease halfway.

Griffin Jones  54:27

How does something like Embie play into this and I'm picking on them because they hit me to you and you've mentioned them a couple of times but this is not a featured sponsor episode, they might do the brought to you by, but featured sponsor means the sponsor gets editorial control. They don't get editorial control. So you can say anything that you want about them we're not going to cut it that you can you can run him through the mud, you could say they're great. You could say that they're that they got a ways to go but what what what are how do they play into this dynamic?

Dr. Cristina Hickman  54:59

So Embie, I met Ravid, she's the founder, very impressive, anybody who has the opportunity to meet Ravid, this she's one of the stars in the fertility field. Her story is that she's had multiple IVF cycles, I can't remember the exact number. It's something like 10 or 12 cycles, something absurd. And she took that as a she learnt with her cycle that she went through initially being quite passive, and gradually being very data driven in her approach to the point where she eventually kind of told the doctor how she wanted to be treated based on the data she had collected. And she, what she learned from this is that she wished she had had this patient app to better understand her care at the time, so many other patients out there that she could support. So she's dedicated her life to create the solution to the patients. Now, before I met her, you know, she had this hugely successful app, you know, 1000s of patients data in there, patients are highly engaged with it, with her app. Her apps are beautiful, she she designs them, she has a marketing award winner, you know, she has an amazing background of skills, and she created the patient side. Now what was missing for me, I was like this poor patients are having to put things in manually every every time. Now, what was amazing about her data is that the patients that were using Embie app, compared to the patients that do not use Embie app around the same regions, you can compare that across geographies, across different demographics of patients, and so on. She founds that Embie app patients have reduced cancellation rates and increased live birth rates. So she presented this data at an estuary this year, you know that the numbers are astronomical, it's like they dropped from 8% cancellation rates are down to 1%. You know, so can't remember, like birth rates, I think it goes up from 46% to 61%. You know, these are these are we're talking about ends of like, 1000s of patients, you know, so so these are significant numbers, with significant improvements. And all that all that she's done, is empowered the patient with their information and provided them insights of similar patients to them, what's happened to them. You know, how powerful is that? You know, to be able, so the patient doesn't need to have a PhD in embryology and you know, I don't know how many fellowships in order to build the knowledge they need. All they need to know is that narrow information about them, to allow them to now participate and engage in the decision making. So this for me Embie app was very, very impressive as a tool. And we've been working together for for Ovum, as well as for Avenues. But this is the Ovum Care project. So we've been working together to create the clinical sites. And this is where all the things we've been discussing today. A lot of these are available within the Embie app. And this is the way that any other clinical they wanted to become an EMR free clinic. That would be the approach.

Griffin Jones  58:04

You've walked us through a number of solutions. You have explained to us the difference between digitalization and digitization. You have shared with us how the digital and the physical environments can blend you've also posited in alternative to having a hub in EMR free clinic would be an interesting follow up topic to bring you back for just a topic about that. But how would you like to conclude our discussion?

Dr. Cristina Hickman  58:32

I think I think we have reached a new a new world to embryology today is so different to what embryology was five years ago. The same goes to nursing and reproductive reproductive care as a whole digitization is the new buzz. You know, the investment in this in this area of fertility has skyrocketed, and the number of very innovative companies out there, they're here to stay. These are not digitized. It's not something that's going to come and go. And we can put the blinders on. And I think everybody who's who's listening in have a responsibility of really thinking through Am I really offering the best standard of care to my patients? Do I need to rethink how to modernize my care so that I can really put patient centered care as a reality in my particular practice.

Griffin Jones  59:23

Dr. Cristina Hickman, thank you very much for joining us on the Inside Reproductive Health podcast.

Dr. Cristina Hickman  59:28

Thank you. It's a pleasure to be here. Thank you.

Sponsor  59:31

This episode was brought to you by Embie. To discover where your time is going and how Embie can transform your clinics efficiency. Visit us at embieclinic.com/report. That's embieclinic.com/report. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary change.

193 Reviewing NYT's Podcast on Yale Fentanyl Incident and Preventing the Next One featuring Lisa Duran


This week on IRH we break down The New York Times podcast, The Retrievals, a five part series that provides an in-depth look at the Yale Fertility fentanyl scandal.

Lisa Duran, who’s consulted dozens of fertility clinics across the US and Canada and was the Chief Experience Officer at Inception Fertility, leverages her experience to offer up methods you can integrate to drastically reduce the likelihood of a terrible scandal at your own clinic.

She provides four big takeaways:

  • A Closed Loop Feedback System (Lisa gives some examples and how they work for patients and staff)

  • Recruitment and Retention (And the risk management necessities involved)

  • Leadership (How to engage your team to create consistent accountability)

  • Service Recovery (Validating feelings, getting more information, and taking ownership)


Lisa Duran:
Website, Lisa Duran Consulting
LinkedIn

Transcript

Lisa Duran  00:00

What happens is, of course, the patients were feeling like, how did nobody believe me? And I was telling my nurse, I was telling my doctor, and why didn't nobody believe me? Whoever was in that procedure room, how was I not believed after that? And and I found myself really thinking about that, going oh my gosh, how do you not believe hundreds of women?

Griffin Jones  00:26

Excruciating pain and public scandal. Those are the topics of a podcast that is much better known and will reach far more people than this one ever will. Well, you might be familiar with the incidence of fentanyl theft by a fertility nurse at the Yale Fertility Clinic that occurred in 2020. You might be familiar with the lawsuits that happened after it. And now there is a podcast that is currently ranked number one in all podcasts, a mini series from the New York Times and Serial called The Retrievals. By the time this episode comes out all five episodes of The Retrievals will be out at time of recording. They're not all out yet. The first episode is about the patients. The second about the nurse, the third is about the court case, the criminal court case that is not the civil one that came later, and the fourth is about the clinic. My guest is Lisa Duran. Lisa's been an in house marketing director for fertility clinics before she was the chief experience officer at Inception Fertility for some years, and she's consulted dozens of fertility clinics big and small throughout the US and Canada on patient experience management tools and leadership capabilities. Lisa listened to all four episodes that are currently out I think more than once she has four big takeaways that you and other fertility clinics can employ to drastically reduce the likelihood of a terrible scandal like this ever happening to your clinic. The first is a closed loop feedback system. She gives examples of those systems, how they work, how they escalate how patients use them, how staff use them. The second is recruitment and retention as risk management necessities and I share a couple of things I learned about recruitment and retention, reducing some administrative time to fill responsibilities that currently fall on your staff. Lisa's third takeaway is about leadership, how to engage your team's hearts, so there's always accountability. And in the fourth, she has three points about service recovery, how to validate feelings, get more information and take ownership the follow through. This is not a bright chapter for the fertility field. Hundreds of women suffered in excruciating physical pain. It's an embarrassing scandal and the cat is out of the bag. These media outlets are huge. And now the topic is very much in the public square. This episode isn't about Yale Fertility Clinic. Lisa argues that this could have happened at a lot of different fertility clinics. She shares why and she shares her takeaway of how you can prevent it. Enjoy today's conversation with Lisa Duran, Ms. Duran Lisa, welcome back to the inside reproductive health podcast for what I think is the fourth time. 

Lisa Duran  02:41

Yes, I'm so happy to be in one. Thanks for having me back.

Griffin Jones  02:44

We're on to talk about a current topic to have one that has just started to wrap up but it's still very popular that more people in our field are starting to find out about it. And it's from an incident that happened back at Yale Fertility three years ago. And the New York Times along with their subordinate companies, Serial, made a podcast that is the most popular podcast right now, a mini series, five different episodes about this incident that happened back in 2020. As it was released, you texted me like did you see this? I said, Yes, I saw this. I want to talk to you about it. I want to have you come on and tell us about how this can be prevented in the future. And we can go through it. Why don't you set it up? Explain to the audience what the podcast is about.

Lisa Duran  03:37

Sure. Okay. Thank you. I'm so excited to talk about this because I was getting texts from friends and emails saying, have you listened, have you listened. And so of course, I jumped right on. It's called The Retrievals. And there have been four episodes. The fifth episode of the last episode is dropping this Thursday. And I just I found just ranges of emotion throughout the, you know, the series of the of this podcast and I wanted to share them with you because I think they're really important. And this is not going to be about how Yale failed. This is not going to be anything about processes necessarily. Or you know, I don't have a clinical background in terms of I'm not a nurse, I'm really going to talk about the experience today. So the lens that I was listening to a podcast with was from the experience standpoint, and so the first episode was about the patients and about their horrible experience and hundreds of patients went through a retrieval with no payment because there was a nurse that was stealing the fentanyl and in replacing the fentanyl was saline. So the nurses or whoever was administering the what they thought were pain meds, and these patients weren't getting them and so hundreds of patients were complaining about pain, you know, going through an excruciating  ordeal without any pain management. And so of course, the first episode just tears rolling down my cheeks for these patients and just, you know, what they what they went through. And it was not just the physical, but it was the emotional of, you know, the, what we do as women is we talk ourselves in and out of things, right. And so many women said that what they did is they found themselves telling themselves stories about why this was happening, well, maybe I'm just not sensitive to, you know, this is just what I have to go through, because my body is not operating the way it should. This is just what I have to endure for this process. And it was just so sad, because we often do that as women is we just, you know, we try to explain it away. And we try to blame ourselves and just say, you know, what, just suck it up and deal with it. And it's going to be okay. And and I think one of the most difficult parts is hearing how after it all came out how they thought, you know, how did no one believed me? You know, how did the nurse not believe me? How did the doctors not believe me how to, you know, if whoever was in that procedure room? How was I not believed after that? And, and I find myself really thinking about that, oh, my gosh, how do you not believe hundreds of women, right? And so we're going to talk about that in just a little bit. So episode two was all about the nurses story. And I found myself tears rolling down my cheeks about her story and thinking, gosh, you know, what could have been done to help her alone? That third episode is about the court case. And of course, you know, you're saying, gosh, she should you know, she should get what's coming to her. But on the other hand, you know, after episode two and hearing her story, empathize with her as well. No excuse for her decision. But and then this last one was so good. It was about the clinic, of course, where was the clinic in all this and what was what was the patient's experience, and as well as the the employee experience, throughout this deal. So those are the four podcasts that I dropped, that you're able to listen to, and what I'm going to unpack during the scene of this talk, as we unpack.

Griffin Jones  07:08

Do you know what the fifth episode is going to be about? Do we know what it will be about before it drops?

Lisa Duran  07:15

You know, that's a great question. And I've been researching and trying to find out and I believe it's going to be more about the clinic and just really summarizing everything, but I didn't know to high. Thursday, Thursday is on my calendar.

Griffin Jones  07:29

And by the time this episode comes out, that episode will be out. But at least we've got four episodes thus far. First about the patient second about the nurse, third about the court case, and fourth about the clinic. And you talked about the patient's feeling like well, I guess I just have to suck it up. I guess this is just the way it is for me. Did they have any kind of recourse where they could have found out if other people were going through this? Is there something that could have been done for to do at least know, for them that this isn't an isolated incident?

Lisa Duran  08:05

Actually, I'm so glad you asked that question, it actually tees up its solution, but I feel would be would have been a great way to catch it early on, you know, what happens is, of course, the patients were feeling like, how did nobody believe me? And I was telling my nurse, I was telling my doctor and why did nobody believed me, I don't believe that that was the case, I don't believe that the women weren't believed. Or that that or that the nurse of the doctor didn't care. What I believe happens is that, you know, there's so many different people, so many different nurses and so many different doctors that are working with patients that they're not necessarily talking to each other. And so they're not seeing a common thread. And so your question, Griffin, about, you know, what, is there something that could have been done? And yes, there should be a formalized process for patients to give feedback, one that doesn't depend on one, two or 10 people to communicate, you know, and then finally, you know, how do you communicate that who documents that you with technology today, there are some amazing systems, you know, Qualtrics Medallia, they have an SMS real time surveying that can by touch point, you know, after retrieval within, you know, 24 hours or after the patient's recovered, can send them a text and say, you know, Lisa, how was your experience, or tell us, you know, how could we have improved this experience? And and if they would have something like that in place, they would have seen a common thread, Text Analytics would have picked it up and they would have seen a very common defect going on, they would have caught it earlier, because they would have seen this, this feedback being woven through a lot of the patient's feedback.


Griffin Jones  09:57

Okay, so there's the opportunity for patients to report using text they get they get how tell us about your visit. It was terrible. I felt like I was going through excruciating pain. It was a 10 out of 10 pain if they had seen this from a number of different people, ostensibly they would have been able to connect a pattern now, is there something in the technology that connects the pattern for them? Would they have to would have to connect the pattern themselves? Would somebody have to be monitoring it actively? In other words, so if they have this, and you get 10 patients in a week that all say I had excruciating pain in my, during my retrieval, that should send up a red flag. But what if nobody's at the helm? Reading it? How does? How does the other end of it work?

Lisa Duran  10:48

Another great question. The beauty of these platforms is that there are two things, there's text analytics, that will compile common themes, and will push them out to leadership. And when you're when you were building the system with whatever company you choose, you create the governance, right, you create the who it goes out to. And and the other thing is, there's a closed loop system that is absolutely beautiful, that if there's a you know, you set whatever the rating is, and if the patient gives it a rating, you know, you talked about, you know, the rating of 10. And let's say they gave it a five and a detractor would be a five. And there's a closed loop system that that does a real time right away alert to the practice administrator. And then the practice administrator can give that patient a call and find out what happened and close that loop. And there are actually systems in place to where, if that doesn't happen, an alert goes to the next person. And if that doesn't happen, then alert can go to the next person. So the idea is that no patient left behind no patient unsatisfied, or no patient that had a less than optimum experience is not followed through with a phone call right away to try and preserve that relationship and fix it. And you better believe that if somebody if a leader is getting no constant detractors on the same issue, that there is going to be some awareness there. And we are going to talk about leadership and in one of these conversations, and we'll dig a little bit deeper into what happens then. But the system is good. And it takes the subjectivity out of things. And it really creates data and, and helps you see, you know how much of a problem it really is. And I believe that this would have been caught a lot sooner had they had a system in place.

Griffin Jones  12:38

So that escalation would help to catch it and not for it just to be another normal issue, because you could have one patient that is keeps dinging you for I didn't get a call back about my lab results yet. I didn't get a call back about you could have that. But if you started, if you really started to get pinged from multiple people about the same issue, it seems like you would pick that up a lot faster, that you wouldn't have to be worried about the boy who cried wolf with this type of solution, because you're talking about a critical mass of people and critical frequency about a critical problem.

Lisa Duran  13:18

Yes, yes, exactly. And depending on how you set it up, as well, as it's not going to just one leader, it should be going to multiple and if an administrative leader doesn't think it's important, it doesn't happen or doesn't get paid attention to. So right, it becomes subjective and one person makes the decision and whether it's initially or not, this takes all of that away, because there are multiple people looking at it. And you see you've got leaders that are really looking at the big picture. You know, if one doesn't seem as it doesn't think it's important, there are many other eyes on it that may may believe that yeah, this is something very important that we need to be addressing.


Griffin Jones  13:58

Tell me if I'm jumping ahead too far, and if I am then un-jump, me back. But how did the patient, while we're on the topic of the first episode of the patients, how did they come to find out about each other? Was it not until charges were pressed on the nurse? Was it, did they find a way to connect with each other in a support group or elsewhere? How did they find out a bit about each other?


Lisa Duran  14:21

You know, that actually in the service recovery piece, that was my fourth, you know, I have four points of my four big takeaways from this and the first one was that having a system in place so that was the first one, the fourth one was on that service recovery piece and how it was handled with the patients and with the team. And so you have they you know, they found out via letter, they got a letter in the mail, the patient's got a letter, not a phone call, but they got a letter and and that service recovery piece, you know, I believe that that we all can be better at service recovery. And so as far as the patients they found out about each other and much later when when it became public when it became when it was on the news and and people started to talk about it, they did not feel comfortable talking about it in the clinic as they continue their treatments, some continued to treatment, some didn't. And nor could they talk to their nurses or their the team about it. And that that was difficult on the team. Because the team was instructed not to talk about it and completely understand that the company has to protect and make sure that you know, nobody says something that is going to damage the company or throw someone unnecessarily under the bus. But there's a way to equip teams to be able to have healthy dialogue about it. And when you tell them just don't talk about it, then it's

Griffin Jones 15:46

One, it doesn't work. Yeah, so I want to come back to that when we talked about service recovery. And, and so in your four takeaways we have the first one was closed loop feedback system, what was the second main takeaway? And what was the third? And then we'll go into them each individually?

Lisa Duran  16:05

Yeah, that sounds great. So the first one was on the patient experience, and you know, what could we do, and it's having that system in place? Where are they they can give feedback from real time, not not the feedback just once you get the pregnant, but each touch point at or at the very important touch points. The second one was, you know, like the second episode, Donna's story, it was the nurses story, and it was the employee experience, you know, I'm in clinics all the time. And I have such a hurt for the teams. And, and I see, you know, firsthand of places where they are equipped and more than where they are unable to give great patient care. And I also see where they suffer, you know, and in this particular case, what happened was, they had two nurses that had quit, and they had a new nurse manager that they were frustrated with. And so they were spread very thin. And that is no excuse for making the decision to autonomy, I want to make sure that that's very clear. What I will tell you is that, I think at times, you know, we think about employee retention, as something very important. And it is, you know, when you look at how much it costs the organization, it's 100% of their salary, you know, to, to recruit, train, or get them up to speed. That's not just about, you know, retaining great talent, it's also about managing risk. And so when you've got a team that spreads so thin, and it's, it's ripe for abuse, and again, very good intentions, with leadership, very good intentions, everybody doing the best they can, but it made me realize that employee retention and talent retention is not a nice to have it to have to have on so many levels. It's not only taking care of the organization, it's taking care of the people that are there, the ones that stay, and a lot of you know, the the nurses that they talked to, they said, you know, we didn't, we don't feel like we could give patient good good patient care, we became a nurse, because we wanted to care for patients. And when we're spread so thin, we couldn't care for the patient the way we wanted to. And one of the nurses said, I just find that I was constantly apologizing, and it wears on you when you're constantly apologizing when your heart is to give good patient care. And I just feel like there's a lot out there. And so that's why this is not about Yale, this is really about, really about in health care, how are we taking care of our people? And how are we ensuring that that when there are openings, you know, we can't always control? And we can do everything you can to be proactive, but when there are openings, and you've got two nurses down in an organization, what are you doing for the people that are there that are picking up? You know, the extra, the extra patients and how are we caring for them? And so that that was my second takeaway on as it relates to this series, but it's the employee experience.

Griffin Jones  19:04

I want to come back to that employee experience to talk about retention and recruitment more, especially as it relates to risk management. What was the third major takeaway for you? And did that also core, seems like each of your takeaways, like you had one major takeaway, per episode topic was the third did the third topic was was that also, did that also correspond with the third episode? Did that come from the court case? Or, or was that a different takeaway?

Lisa Duran  19:28

Actually, this was the only one on the court case. That was more of an emotional takeaway for me, because, you know, if I would have just listened to episode one, I would have been like, you know, throw her in the slammer. That's terrible to say, but after hearing her story, it reminded me that every life has a story. Right? And, and what could we have done? Or what could you know, what were the signs that we could have taken better care of her again, that's no excuse. There's lots of people that have the stress that she has, that doesn't that don't make the decision she makes okay, so there's no excuse. But the court case I just found myself, like the judge, actually, you'll hear the judge talking about not quite knowing how to navigate this, because you see both sides of it. And so so there really wasn't a huge takeaway, other than just my personal emotions on it, just the roller coaster of it.

Griffin Jones  20:20

So what was your third takeaway?

Lisa Duran  20:22

the third takeaway was on leadership, you know, and it's so funny, because what I'm doing now is, it's called an integrated experience, because I don't believe that you can just create a patient experience program, and scale it across the company and expect it to be fabulous, right? You've got to have great leadership a place to catch, you know, catch those wins, and celebrate those wins. And then coach for behavior change. And then, and then there's the employee experience, you know, people don't do what organizations expect they do, it's paid attention to, and they and you know, you want their hearts, you know, In leadership, we don't just want people's compliance and health care, you absolutely compliance is critical, we have to want their hearts because if we have their hearts, then they're going to take great care of the patients. And so what I found, my third takeaway was with leadership, you know, one of the, actually, the hostess, the host of the podcast said, who was managing Donna, you know? And I see this so often in clinics, you know, there's been a nurse that's been there 15 years, and she hands the nurse manager or the senior nurse or, or she, and there's a lot of trust put in that person. And I'm not saying it's not rightfully put there. But there needs to be accountability, not just systematic accountability, you know, for the meds and, and all, but there also needs to be personnel accountability at every level. And so where was, who was managing Donna? And who was the leader that was looking at the big picture. And so often we find that the in health care that there are managers that are managing tasks, but not leading people. And so it just, you know, it made me think of this new manager that they were very frustrated with, what was her experience or his experience? You know, what, what was that person's onboarding experience like? Is somebody coming alongside them and helping them to build trust with the team so that they can have healthy dialogue? You know, what was that manager's experience like? And so without good leadership, without strong leadership with people leading and servant leadership, then again, it's right for abuse. So that was my third takeaway.


Griffin Jones  22:32

You're a very efficient thinker. I know your your points don't perfectly correspond with the episodes, but they almost do and it makes it very easy to follow. So episodes go patient, nurse, court case clinic, your major takeaways go closed loop feedback system, a retention and recruitment as a means of, of risk management, leadership and accountability, and then service and recovery. We talked about the closed loop feedback system. Before we get into your second major takeaway. I am curious about what you found to, to what tugged at your heartstrings with the nurse because I think of you as somebody that actually probably wouldn't be a good person to have on a jury. Like in a liberal democracy. I feel like Lisa Duran is the type of person that you want on a jury to give to give fair jurisprudence to people and I think of somebody like my dad who has been selected for, not called on Lisa, selected for jury three times because he's so even keeled. My dad's the type of guy that you want on a jury. And I feel like they sit around somebody that you want on a jury. But what swayed you about the nurse?

Lisa Duran  23:04

Well, there were so many things, you know, she's a mama herself. She has kids. I think what drove her to the decision, you know, when you hear her life, and you hear about her, her marriage, that was a very unhealthy relationship. And you know, there were some some verbal abuse, emotional abuse, and how it was a very unhealthy situation. And you know, that it's my very favorite video is that Chick fil A video that's every life has a story. And it just really reminded me that, you know, what drives somebody to do something like that. Is this a bad person? No, I don't believe this is a bad person. I believe that this was a very, very hurt person who needed some intervention who needed some help. And so, you know, my heart went out to her, but then you get back to listen to episode, one and you hear these patients? And you're like, oh, it just I don't think I would be a good pitcher because I think I'd have a hard time making that decision.

Griffin Jones  23:45

You lean too much towards mercy and not not enough towards justice in that scenario.

Lisa Duran  24:15

You said that very well.

Griffin Jones  24:25

Well, then talk to me about how retention and recruitment are a means of risk management, and you alluded to it as you were covering the you're giving the synopsis of the point, but I want to hear more about how it's not just for to have butts in the seats. It's not just for productivity. It's not just for the the cost impact of having to retain and recruit somebody new and train them and that being 100% of their salary. But there also is risk when seats aren't filled. Tell us about that.

Lisa Duran  25:31

Yes, well, you know, my entire career, I've been doing patient experience, patient experience as a differentiator patient experience as it's the right thing to do, right and patient experience, as you know, it's it's a good thing for the team member, as well as the patient and their and championing for the patient experience, as as a good thing as a differentiator. And this made me realize it is all of that. And it is also risk management. Because it really highlighted the fact that when teams are spread very thin, what could happen in that, and this happens to be, unfortunately, a scenario that that's exactly what happened, a very skeleton crew, and now a new leader. And, and a decision was made without accountability and, and people that are spread too thin to pay attention to some of the cues that would have alerted them to something's not quite right. And they did in, in the podcast, I think it was, yeah, I think it was episode two, they and episode four, they did some of the team members did talk about some things that just didn't seem quite right, there were a few things that were off, but they're so busy, right, they were just going from one patient to another that they really didn't have time to process that or communicate that, you know, to each other or up to a leader who had the big picture in mind to, you know, to get that off of the pass or to, you know, address it or at least ask the right questions. And so when you have when people are spread, then it really becomes a risk management, not just a good thing to have for patient experience. It's also and it's also retaining the good people that you have, because, you know, as a few of the nurses said, Well, if we don't feel like we could give good patient care, you know, we come somewhere where we are equipped to give good patient care. And if there is an urgency in filling the positions with the right people, and please know my heart and that I think HR, HR leaders have the hardest job ever, just trying to find the right people. And they're working really hard to do that. And so hats off to the to the HR community right now. And this is really hard with a with a with a short list of people or with a shortness of of talent, of good talent there. So I know it's hard, and it's hard. But it really highlighted that this was, you know about patient experience, it was really about risk management as well.

Griffin Jones  28:03

Do you have any solutions for service because on the feedback from patients point you, you get a closed loop system, whether it's a self checks, whether it's a Medallia, whether it's another software, and you walked us through a little bit about how that can work, other than just posting more trying to raise salaries, trying to to maybe give people more benefits, or whatever it might be, do have more suggested solutions for how these managers might retain staff and recruit them for longer so that they don't make themselves liable to risk with a shortage like this?

Lisa Duran  28:41

Well, there are two things in your question. One was in how do you retain staff? And the other one was, you know, what can we do in the recruitment process? Or is there anything you know, that you can do? So I'm going to first address the retaining piece, and you know, how you retain people, if you care about them? Right. And so often we think the employee experiences, you know, is a pity party, or, you know, and those are good things, please, I'm not minimizing that, but you know, professional development pouring into them personally and professionally. And there's a way to do that, really caring about them, you know, building trust with with their direct, that's what the leadership piece is so important. And I've been probably doing 90% Leadership Development nowadays, because, you know, health care leaders are so often promoted into these positions, because they were good nurses and they weren't good, you know, in patient services, or they were good in financial concepts and they are not given the tools to really to lead people, they can manage the tasks but not lead the people. And so, you know, the, in my personal opinion, I would say that the biggest retention strategy is leadership development and how to lead people and how to care for them and how to be servant leaders. And that is going to make people want to stay you know, not go across the street for another dollar an hour, when you really win, and you know, we've all worked for people that really care about us, and we will, we will stay, despite her times, we will stay, you know, you know, just despite all the hardships because we know that we're cared for. So that's on the retention piece now on the, when it does happen, and you can't always control that, right when it does happen, and you've kept openings, this is going to sound a little cheesy, but you know, me, I'm cheesy, but giving oxygen to hope. And I know what I mean by that, is that so often the clinics feel that it is a secondary priority, to fill their open positions. And I know and I know, for a fact, with a few organizations, that is not the case, it is their number one priority. They you know, people don't often see the back end of all the people they're screening, you know, they're trying to find the right candidate, not just any candidate, but where the breakdown is, is in the communication. And it's, it's HR, being able to communicate or communicating the right message and giving oxygen to hope. And speaking to the fear of the clinic of the people in the clinic, and I know you're spread thin, and I know you're working hard, and it doesn't have to be HR is lucrative, I know you're working hard. And know that this is our first priority, and I am I'm screening 60 people this week, and I want to find you the right candidate. And those messages aren't always happening. And you know, when when people feel that, that their sense of urgency is your, your sense of urgency is their sense of urgency. It's amazing how much that could just kind of that how much better they can feel about, okay, I know, and give them confidence in the organization, they're working hard, because they know they're doing the best they can. And they know that it's a priority. They know that there's a sense of urgency there. So you know, speaking to the fear, giving oxygen to help, and communicating that this is absolutely there.

Griffin Jones  32:03

Let's use that as a segue into leadership then and talking about how to engage their hearts to lead them to instill that accountability, because that is partly also a retention tool. I gotta tell you this, I've probably you said, we've all worked for that type of people that really has engaged their their people like that. I've both been that person and both not been that person. And I've not been that person at times where you're crazy busy. And clients have a lot of needs, and your recruitment or retention pipeline is slow. And and then managers can end up taking on a lot of have that responsibility. And then they can become resentful at one time or another. And you know that that servant leadership can be difficult at a time, it is really difficult in a time where you're like, I am working my tail off, and I can't hardly sleep. I'm working from seven to 7am to 10pm at night. And I am totally focused on this. And I'm trying to keep my team from feeling that burnout. But yeah, eventually it's like, yeah, get the damn thing done like and and then you turn into a manager that you might not have been previously. And, and so I'm wondering if you can talk to that a little bit about from the leadership coaching of how you can be that leader at a time when everything is under water, where so many fertility clinics are right now?

Lisa Duran  33:41

Yes, yes. And I have to tell you, the organizations that I've been working with are amazing, and the hearts for their people are there. And you know, we can't always control our circumstances, we can't always control what happens in terms of people leaving, you know, or things that happen processes, protocols that need to be changed. But one thing I was put when I'm working with leaders who say my response is my responsibility. You know, I can't control what's coming at me all the time. My response is my responsibility. And I know for me, when you said you've been that lead, you've you've you've been that leader, and you haven't been that leader, I say very much the same. And I have an executive coach who has just been amazing and she talks me into the ledge all the time, and like help me get me out of my emotion, you know, help me to help me to formulate a response that's caring and and that validates the feelings of the teams as well as holding them accountable. And one of the things that I'm finding in clinics is that leaders are so afraid of losing someone that and I spoke to this on the last podcast, I believe, are so afraid of losing someone that they're not coaching for behavior change. They're not redirecting that, that toxic or that negative behavior, especially the leader, right and, and so equipping them for two things, equipping leaders to be intentional to celebrate those wins to be on the floor to, to put the task stay on, and it to be on the floor with their people and intentionally catching them doing something right. As well as addressing those, you know, those negative behaviors or those toxic behaviors, the gossiping, the negativity, the complaining, you know, it was complaining is like vomit, you feel better afterwards, but everyone else around you feel sick. And so. So as leaders really working with them, I'm getting very comfortable at that skill, and teaching people how to have a voice, but how to do it productively, and how to do it in a way that inspires change. Rather than just feed and plant seeds of negativity. You know, those are the things I think that that are bringing the most change in, in my experience, what I'm doing. And certainly just understanding my response is my responsibility. And as a leader, we have a responsibility that the words that come out of our mouth are optimistic, they don't have to be positive and lying, we can say, you know, we can say things are tough, you know, the definition of optimism is not the denial of the current state, the definition of optimism is saying, you know, this really sucks, or this is really hard right now, but it's gonna get better. And this is going to help, you know, streamline things for us so we can give better, you know, patient care. And so that that attitude of optimism and holding people accountable, catching them doing something great. And then realizing and teaching and just cultivating the call for the culture of my response is my responsibility. Those are the things that I that I'm seeing are really helping.

Lisa Duran  36:47

That axiom that you talk about of complaining, it's like vomiting, you feel better afterwards, but everyone around you feel sick, I really tried to take that into other areas of my life to lease and I think I hear your voice saying it to me, in my own head, like I want to, I want to complain to my wife, when she gets home about how the tech didn't show up, you know, to fix our Wi Fi or whatever, and try to like, who's that going to make feel better? Me for 10 seconds, and then you know, I'm just going to dump all over her day. So I try to I try to carry that into to other areas. You've mentioned, you've mentioned several times during this interview with this isn't about Yale, but let's take a similar situation where we have a clinic that is down at least a couple nurses, and and you've got managers running around probably doing a whole bunch of things out of the normal scope of their seat, how would you coach them from a leadership perspective to where they can still hold people accountable,

Lisa Duran  37:54

I'm not gonna claim that that's an easy thing to navigate, it is very challenging, especially because, you know, the rollout of new software, or the or the changes that doesn't stop regardless of how many openings you have. And so that could definitely present lots of challenges for a leader. But by showing them and coming alongside them, and really, really coming alongside them, arm in arm, and saying, you know, you can do this. And you can do this by identifying those that can do it with you, you know, who's going to come alongside you in the clinic and champion for that optimistic attitude. And, and prioritizing things in again, going back to caring for people. What happens so often in these situations is they're managing the tasks, and they're trying to fill their positions. And I was in a clinic once when the practice administrator had to be in an office screening, you know, resumes for, you know, six hours, and I thought that's, you know, and it was so hard for her because she wanted to be on the floor with her people. And so, you know, really just carving out time and putting those, you know, putting the tasks down where you can and investing in people and making sure that you're talking to people on the service recovery part. One of the things that hit in that episode for was that the patient is well as the teams were saying, we didn't get any genuinely caring communication. Nobody addressed our feelings about this. It was always the legality, the legal language, and anytime in service recovering I think that your question of how you know when there's a situation in clinic where you're short staffed and in and all those things, it's a little bit like surface recovery, where you have to speak to the fear. And you know, fear is a liar. Fear is a liar, but we listen to it. And so when patients are fearful because they're continuing their treatment in a situation like this, and they're walking into a clinic and they can't talk to their nurse about it because our nurse has been, you know, told you cannot say anything, you know, how can that nurse help alleviate those fears? You know, we need to equip people to speak to the fears. And equipping them means teaching them, you know, the verbiage. You know, what kind of verbiage you would say what would you say to a patient? And it's similar for a leader with a team? What do you say to your team? When you know they're working their tail off? Do you just tell them? Like do with it? I'm working on it? Or do you say, Look, I know this is hard, and I appreciate your hard work and just know that this is my number one priority. And I'm working hard to fill this and you know, is there something that we can do together? Yeah, what ideas do you have, you know, really partnering with your teams in the solution. And so often, leaders feel like they have to fix everything, when when you know, the teams sometimes have the best solutions. And so really partnering and not feeling like you have to fix everything. But caring for people is, would be my best advice.

Griffin Jones  40:59

I want to give something to the listeners that you made me think of when you talked about that practice admin that was going through 60 resumes, or however many you said, two hundred resumes, or whatever you said it was. And there's plenty of people listening that have to do that. And it's dozens or hundreds of resumes. And one thing that leaders can do that I did that completely changed my business was hire someone else to do that to go through the resume. So by the time my hiring manager gets a resume, it's a short stack. And the recruiting specialist, the HR person is going through those interviews, before going through those resumes, doing the screening interviews, like the 20 minute screening interviews, that are only a few questions, and then bring those to the hiring manager so that you are going through this process faster one, and two, you're not asking the hiring manager to do all of that. That was a life changer for me. And a lot of people are listening and think, well, I can't hire that person, because they were a small practice, you can hire that person as an independent contractor, you can hire that person part time. And for all the economic reasons that Lisa talked about, as well as the risk mitigation liability that she's talking about, it is a much cheaper solution. And I strongly recommend people do that I get more into that topic with Dr. Eric Widra, that episode will come out after this one does, but I am telling everybody listening, it totally changed my business. I was in a position where you when you're trying to do all the things that Lisa is talking about and and you do that for a while, and then you do it for a little while longer. And you're and you're still at this problem where, you know, maybe when you are trying to involve your team for solutions, you're involving them in areas where they shouldn't be involved, because they're supposed to be accountable for other things, I was doing all of that. And, and now having the system has made things better, I was key, I was not rewarding people quickly enough, I was not dancing, growing some people. And then because of that, I was also letting other people that should have been fired in two seconds, stay on and, and and, and not contribute to the solution. So that's a huge, huge thing that I think leaders can do. Get a couple of recruiters have some redundancy in HR, it's okay to have some redundancy in HR, you can do it at a part time, hourly independent contractor level, if you have to as long as it's scoped properly. And that can can really to help with some of those odd things. So you've talked about some that leadership coaching of how they can approach their teams about being prepared for the responses being prepared for the conversations, then how does that lead into service recovery? In, in your view? What what happened in this situation? And what should it look like?

Lisa Duran  43:58

Yes, service recovery is more than just when a patient is upset. I mean, that is that is worse teaching me how we talk about service recovery. Very, very important. But the concept, I've got three steps that I teach. And the concept is very relevant internally for leaders with their teams, as well as externally, with teams with our patients. And the step that we always forget to do is validate the feelings. And when I talk about, you know, speaking to the fear, when you're talking to a patient who was fearful that you know, what if this doesn't work, or what if i What if, what if I didn't pick the right doctor, or what if my body's just not going to respond? You know, when you can speak to that fear. When you can say, gosh, I could understand why you're feeling anxious. Even, there were so many emotions to this. Like, you know, I would feel that way too. And just now we're here for you. Right that venue foof then you kind of did, I wouldn't say diffuse But you communicate to the patient, or the person that I'm on your side, I'm on your team. It is not, I'm just trying to fix something for you. It's, I'm on your team, and I get it. And it's very normal for you to feel the way you're feeling. And it's the same. So in this situation, patients didn't get that. Right. So they relied on each other. And, you know, so there they were all in one camp. And then same with the organization that the teams did not. I'm not claiming that they didn't, it didn't sound like they did. Because they were told don't talk about it amongst yourselves, don't you know, share. And and firstly, they said, How can we not? You know, right, we're very affected by this too. We were very, we were betrayed by Donna as well. And so how can we not talk about this. And so speaking to their fear, and just saying, just, you know, if the organization were to fear, the leader, were to say, Listen, I know that you're fearful of the press of what's going to come out, and that people are going to think that you're working for an organization that's not desperate, that doesn't have their act together, or doesn't care about patients. Let me tell you, that is so far from the truth. And this is what we're doing to prevent that from going moving forward or from ever happening again, right, you're speaking to that fear, that's really important. You're validating those feelings, so that when you go to the fix that place, they're ready to receive that, fix it. And so and so the first step is validating those feelings. The second step is getting more information, tell me more about that. Invite the patient, invite the team member to talk to you about how they're feeling or about the situation or giving you facts, so that you can, you know, fix it in the proper way. And then the last one is to take ownership, right, and it may not be my fault, but it's my problem. And, and taking ownership of the follow through and not just, you know, sending it off to another department that you cross your fingers that someone's going to call you. So you personally following through. So it's a very simple three step recovery process. That really, and I think I realized that during this podcast, in that episode number four, that the service recovery that I've been teaching all these years for patient experience is very relevant here and the team member experiences as well.

Griffin Jones  47:17

so you validate the feelings, you get more information, and then you take ownership of that follow through, is this something that people can do even if there's a legal liability, because if I've done something wrong, I want to admit it, I want to share what I've, what we what we're doing to change it. I've also never been in a situation, this public profile, this high level of stakes, and it's all the lawyers that are involved. And I could only if my lawyers are telling me shut up and just keep your mouth shut, then I would feel it that would be really conflicting for me because it's like we did something wrong, I want to take ownership of it. But I also don't want to maybe accidentally take ownership of some legal liability that we really aren't responsible for. How it can they use this in this? Like, maybe that's what you were saying about not? It's not my fault, but it's my responsibility. They still, here's what we're doing to change it. Do you have any thoughts on what that would look like in a really litigious environment like this?

Lisa Duran  48:22

You know, Griffin, I will tell you, I feel very equipped, ill equipped to answer that question because I don't have any legal background. And I understand the risk of somebody saying the wrong thing. And I appreciate them trying to control that I really do. And so, so I think my service recovery in this situation was really more about leadership. And, you know, following the guidance from their legal counsel, absolutely. Follow that. And you know, that, does that mean that you also can't, you know, get your team together and have a very honest conversation about, you know, I understand how you're or tell me how you're feeling, you know, you just just tell us how you're feeling. Tell me how you're feeling, right? And, and to have some of those conversations, of course, within the boundaries I mean, you know, managing the risk there. And so, you know, that would be something that I would hope, though, that a leader of an organization, or a high level leader, would have that conversation with our legal counsel, and how do we take care of our people? What can we say, what can we do? What can we do with patients? Or can we say to patients, and it felt like and I'm just gonna say it felt like because I don't have any proof on this patient is perceived that that the organization was just trying to to care about the organization. And so I think that the question to your legal counsel, is, how can we maintain the boundaries and what we need to be doing legally as well as take care as well as care for our patients and our teams during this time

Griffin Jones  50:01

People can check out this mini series. It's called The Retrievals, The New York Times Serial podcast, by the time this episode comes out, all five of the episodes of that mini series will come out, it's called The Retrievals. First episode about the patient, second about the nurse, third about the court case, fourth about the clinic. Fifth, to be determined, but you've walked us through how we can prevent these incidents in the future by first having a closed loop feedback system. Second, by having by equipping the team to for retention and recruitment of personnel and viewing, recruitment, retention and recruitment as not just economic nice to have, but it truly is a risk mitigation factor. I talked about enabling leadership to engage the hearts of their team and to employ accountability. And then you also talked about three points for service recovery when something like this happens, and you need to make it right. What did I ask you? And, and or how would you, how do you think we should conclude this topic?

Lisa Duran  51:16

Thank you for asking that. Actually, you asked everything. And so thank you very much for that very engaging conversation. And thank you for putting in your your experience with HR and what you did. I think that's really helpful. I think that I, you know, when I first listened to this podcast, I wanted to hide it from everyone, because I thought, I didn't want any future patients hearing this, because they're going to be so afraid of fertility treatment. And so, so I strongly recommend everybody listen to this podcast, and I recommend that you listen to it with a heart of not looking at how the system failed, necessarily, but looking at what we can learn from this. And I'm realizing that although one person made a really bad decision, there are hundreds of thousands of people, there are hundreds and thousands of amazing nurses, amazing doctors, amazing leaders, amazing patient care specialists out there that are taking great care of patients every single day, and helping them achieve their dream of a baby or family. And so, so you just to go into it with that thought and that idea and putting things into perspective. And that, you know, this was one person's decision out of so many people that make great decisions every day, to really care for people, and just really going into it and what you can personally and learn from it. I highly recommend this podcast.

Griffin Jones  52:44

We'll include your contact info in the show notes and pages, but for those clinics that could use some leadership help they could use some team help with with some of the things that you've talked about today. How can they get a hold of you? 

Lisa Duran  52:58

Yeah, they can call or email me, they can go onto my website, which is lisaduranconsulting.com. I have all my contact information there. But yeah, I would love to come alongside you. And it's that integrated experience. It's not just one. It's all of it. It's leadership, development and patient experience and internal culture. That's the secret sauce. Thank you, Griffin. Thanks for having me.

Griffin Jones  53:20

Lisa the pleasure's always mine. Thank you very much for coming back on the inside reproductive health podcast. Thank you.

Sponsor  53:27

You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

192 How to solve IVF medication cost uncertainty. BUNDL with Medications℠. Featuring Cheryl Campbell and Karol Bonilla

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


🔹 Learn from Cheryl and Karol about the significance of vertical integration in the fertility field and explore how this strategic approach is changing the landscape of fertility treatment.

🔹 Gain insights into how BUNDL's program alleviates this burden and contributes to a positive patient experience, reputation, and online ratings for clinics. 

🔹 Explore how BUNDL's transparent pricing model gives patients peace of mind upfront, allowing them to focus on their treatment journey without financial worries

🔹 Delve into how BUNDL collaborates with lenders to assist patients in affording comprehensive fertility treatment, enhancing trust and communication.


Karol Bonilla, Inception Fertility LLC:
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Transcript

Cheryl Campbell  00:00

This is what we do at BUNDL we give the information so that everyone can make their most informed decision and put their fertility dollars where they know they need to go.


Sponsor  00:09

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients. Please visit www.bundlfertility.com/medications-cost That's bundlfertility.com/medications-cost. Today's episode is paid content from our feature sponsor who helps Inside Reproductive Health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

Griffin Jones  00:58

Assurance and certainty for stressed and anxious fertility patients relief for burnt out IVF center staff achieved by means of finally accounting for medication costs with IVF treatment costs a pain point that I've heard about for a long time. So far I haven't really seen a solution for perhaps until now because this is the topic of today's featured sponsor episode Cheryl Campbell from BUNDL is back you remember her, she's the director of operations at BUNDL. BUNDL is the financial program that packages multiple treatment cycles together at a reduced upfront cost. And you may have heard her because she's been on the show before this time show brings out her colleague Karol Bonilla. Karol is the strategic account manager of Inspire RX inspire RX is the pharmacy services program that utilizes preferred network pharmacies to give patients discounts on fertility meds to speed up delivery and to personalize their Med Service. Wait. So is this a BUNDL show? Or is this an Inspire RX show? It's a BUNDL show and one of the key topics that we talk about that you're very interested in is a fertility executive as a practice owner is vertical integration, we talk about the importance of vertical integration, and we give examples of how it's changing our field. Right now we talk about the stress that patients face when they're not able to account for medication costs, what that does to them mentally and emotionally but also what that does to the practice how it's harmful to the practices reputation and online rating, how it's harmful to practices scheduling when someone has to cancel an IVF cycle start and that negatively snowballs to impacting other patients. We talked about the medications that BUNDL with Medications℠ covers it's all but two, one that's off label and one for which there's another brand. Cheryl and Karol say that once a patient pays for medications upfront with their BUNDL program ask, well what happens when the patient needs more, as often happens, and they tell me the patient gets those meds at no additional cost. Take a listen because I try to dig out if there's any catch. The whole point of BUNDL is to give patients peace of mind up front we talk about taking something off of the plate of your staff so they're not getting phone calls without medication orders. Finally, we talk about a problem that both patients face and that you clinics faces when patients can't afford treatment and how BUNDL works with lenders to help them afford treatment but also to help them hone in on that one number that all in number. I know none of you fertility clinics want to treat your patients like you're a damn car dealership. You know how car dealerships are? Oh, this is the vehicle price. But then there's this fee and that fee and the other? No, you just want the out the door price. And your patients want to know what that one all in number is too. Outside of a company standpoint, it's also fun for me to hear the passion in Karol and Cheryl's voice and I give them a compliment at the end that cost me nothing to say enjoy this feature sponsored episode about BUNDL with Medications℠ with Cheryl Campbell and Karol Bonilla. Ms. Bonilla, Karol. Welcome to Inside Reproductive Health. Ms. Campbell. Cheryl, Welcome back to Inside Reproductive Health.

Karol Bonilla  03:56

Thank you. 

Cheryl Campbell  03:57

Thank you.

Griffin Jones  03:59

One of the reasons for interested this topic for me was when I first started working in the fertility field or with the fertility field, that was when I was coming in as a generalist marketer didn't know anything about the fertility field. One of the things that I did was I emailed every peer support group leader in America off of resolves list. That's how I got to know resolved because they emailed me and they're like, who are you? And I, every peer support group leader and I said, Hey, I'm some guy with no medical or scientific background that doesn't know anything about your problem. That's thinking about starting a business here. I just want to know what you are finding to be the biggest pain points as you're starting your journey. Would you be willing to talk to me? And I was amazed by how many of them said yeah, we'll talk to you and we'll just share what's going on. And there were three resounding patterns of confusion as people were starting their journey one was about success rates. The second was about out communication getting communication back that people were really frustrated with. And the third one had to do with cost and specifically about costs, they weren't just complaining about high costs or not being able to afford it, they were really talking about cost confusion, having no idea how much their treatment was going to cost. And a big part of it was that medications aren't included with a quoted cycle price, there could be this huge range and variability. And that was in 2014 2015. And the status quo, it pretty much remained in place for a long time. Now something different is happening. And I want to talk about what that is. But first, I want to talk about, can you talk about why this is such a pain in the neck for patients, when they don't, when they're not able to account for medication costs are no even what they'll be.

Cheryl Campbell  05:58

I can take a little bit of that I think what we hear from patients is that it is, you know, once they wrap their head around what their IVF treatment will be and what that journey might look like and have a basic idea of, you know, the services that they will have to go through and their likelihood of success. That's one massive knock itself. And then all of a sudden, you've got this meds piece, which again, as you alluded to, can vary so greatly across the range. And no meds means no start, right. So if you can even reach the mountaintop on the meds part, you're you're delaying this, this dream of even starting this journey, which again, is daunting, but but you're not going to be able to start your your, you know, there's a breakdown as such at your at your practice, you know, your schedules are off, the practice schedules are off, the doctor can't start you when he's looking at your clinical and saying, you know, you really need to start you're in that bucket of we've got to get you moving into this journey. But you're just stuck on this diet of not being able to get the meds. And I think that's the most heartbreaking part of not having made enough strides on this med piece is really that patients are stalled and can't get moving.

Griffin Jones  07:10

And so you're ready to go for treatment, you've accepted it you are you talk with your partner about it. And then I can only imagine what that's like to then not be able to start a cycle. How common is this? Are you hearing this from a lot of people?

Cheryl Campbell  07:28

We hear it from a lot of people, yeah. I think you know, when we talk about even just going through the pieces and parts of our multi cycle program, you know, the next question always, most, I think 90% of the time is, what can you do to help me with meds? I've heard that this is this mess piece is what's going to, you know, really have me down a rabbit hole? And what kind of help can you give me? What kind of of tips what kind of due diligence? Do I need to do? You look, the majority of the time clinics are very helpful practices want to work with patients, but you know, they're, they really get stuck on that. And so we we offer a lot of counsel as much as we're able to sort of help guide them in that direction, but we hear it a lot.

Griffin Jones  08:10

You talked a little bit about the impact that that has on practices, because they've got schedules in place, they might have a certain number of people that they can cycle, and then it messing up the clinic schedule is messing up the lab schedule, and that impacts the clinic and impacts other patients because maybe somebody else could have had that spot and it's a last minute cancellation or can you talk a little bit more about that?

Cheryl Campbell  08:39

Yeah, I mean, look, you know, starts are important practices batch starts, they want patients to be in a certain flow, you know what doctor, like I said, I'm I'm not a physician, but I'm imagining they're looking at the sort of scope of a patient and what's going on with them and what their clinical diagnosis is, are and, you know, maybe their ovarian reserve is already low. And now you're going to miss six months, maybe nine months, because the patient is basically trying to make that you know, payment and get to that point with that meds piece. So it I think it just throws off the whole rhythm of how an REI wants to help treat that patient. And I think yes, is even as a part of the larger scale of the practice, you know, cancellations and setting people back and like you say, maybe somebody else could have started and it's throwing that rhythm off. So I think it can I'm not saying it's going to drive a massive rift, but I think that it can throw off that relationship as such. There's nothing worse you want to hear then. Okay, well, let's see how we do next month. We can't start you this month. But you know, we'll try to get you on the schedule for next month. I think that just as a whole breakdown in the relationship when that has to happen.

Karol Bonilla  09:45

I would actually like to add to that. As far as like, you know, the emotional heartbreak for that patient is that you know, just to echo back what Cheryl was saying, maybe you don't have extra two months. You can't so then you know have that dream of having your family it's not going to happen, not at least in this route, because the the one thing that for a patient is can I do treatment? That's the first milestone. Now can I afford treatment because of insurance, that's the second milestone. And then is is my insurance going to cover these medications? That is the final one, because and if they don't, it will be a matter of a few thousand dollars. And even though it doesn't sound significant, it's very impactful, and you know, they can start. So it's heartbreaking. 

Griffin Jones  10:32

I also want to say that it really can impact the relationship, because very often, when we do reputation management for fertility clinics, one of the things that we're seeing has to do with rescheduling or not being able to schedule or something gets thrown off and was looking at our fertility clinics, reputation yesterday that we're starting to advise on. And the most of their reviews were overwhelmingly positive. And a couple were things like, you know, this had to be rescheduled. And so they hadn't even either been in some cases. In other cases, they were talking about it, that wasn't new patient consults that they were talking about later on in treatment, who knows that might have been associated with something like medications, but it does impact the patient relationship, it impacts that patient's relationship with the clinic, but then it also impacts everyone else's, because that patient is going on online and talking about having a negative experience. And it's something that it has been out of the practices controller, at least up until recently. So now, there's this medication piece that that BUNDL is offering BUNDL with Medications℠. We talked about the reasons that there's a need for it with patients and practices. But tell me more about what motivated you all to know that this is something that we can solve?

Cheryl Campbell  12:03

Well, I think from a you know, having started BUNDL knowing that the goal of that was to help alleviate that financial tension that financial stressor right by by meeting patients more and more where they are in their journey and being able to take all those little pieces and parts and put them into one place for a patient and help them kind of get their start going. And and not worry about the financial aspects of it and focus on the treatment. So the meds piece seemed like the next logical avenue on that front. And because BUNDL and Inspire RX are a part of the same team, that the relationship just seemed like it was a no brainer, right? This is this would be a simple way for us to combine our forces, and take our multi cycle and layer in the meds and do it at a price point that will be very desirable for patients. And the price is really important. I think we're doing that well. But I really think that it's we never I always say this to my team. Never underestimate just when you're able to put one more thing in our bucket to help the patient and take it out of the strain of the patient. That's such a win for them. So I think it's just another way of saying we'll handle it, our teams are going to take care of it, you don't need to worry about it. And you know, that's really the genesis of it. And we find that, you know, it's it's landing really well with our patients.


Griffin Jones  13:29

Karol, tell me more about how BUNDL partners with Inspire RX?

Karol Bonilla  13:35

Well, we are under the same umbrella through inception. So we're pretty much family. So Inspire RX pretty much is our pharmacy benefits platform, we have a group of filling pharmacies, we're there to provide those patients with discounts through reputable filling pharmacies. So right now, our connection between BUNDL and Inspire RX is to fill that gap, you know, you got the treatment that you're going to have on medications. Now those patients thankfully don't have to, and I hate to use his word shop for medication pricing that's done. It's done through this partnership. So that, you know, voyage of going into that that could be kind of dark, because patients could get so many, a lot of misinformation or even you know, going to these message boards and saying, You know what, maybe I could get medications abroad. That's not safe. So all that those unknowns are out of the way thanks to this partnership.

Griffin Jones  14:35

You mentioned a partnership with a multitude of pharmacies and some pharmacies serve some states and but not others with you've got multiple pharmacies. Are there any states that you're that you're not able to cover with this partnership covered?

Karol Bonilla  14:51

We're covered nationwide. 

Griffin Jones  14:53

So then it's so it starts to come together because you've you've got the finance same piece with BUNDL. It's the logical next step, you also have a sister company and inspire our acts as all these pharmacy partnerships. And then tell me how does it actually start to get built? 

Cheryl Campbell  15:13

As far as the process how the process goes?

Griffin Jones  15:15

Yeah, of making it would be even before we get into the process for patients, but just like, like, how did how did agenda bring this to market? Okay, we've got the need, we've got the finance piece, we've got the pharma piece, tell me about how you brought them all together?

Cheryl Campbell  15:30

I think it was, I don't even think it was too much to bring them together. To be honest, I think because Inspire RX was such a strong line of business as well as BUNDL, I think it was just a question of, how do we find between the teams with the best working situation was we marketed it during National Infertility Awareness Week, which was fantastic, big launch then. And I think it just, you know, we just kind of put the word out. And, and, and said, hey, you know, this is just another addition, this is an add on to your existing BUNDL conversation, you don't have to partake in it, but we really, you know, want the community to know that we're, we're listening, we're hearing, we want to meet them where they are. So we have this additional add on. And, you know, we did a lot of push out into our practices, making sure doctors don't know that they're able to talk about it. And that now is a part of, you know, our offerings. So I think because our two lines of business are so strong, and in what we do the crossover of, hey, you do this, I do this, we come together. Yeah, it's really been very, very simple. And I think it's the strength of our relationships to care, like Karol said, very strong relationships with the pharmacies, very good up and running relationships with our practices. And I think it made it a simple transition.

Karol Bonilla  16:46

It just makes sense. You know, if there's that need, we can fill that gap. So

Griffin Jones  16:52

An overnight success, X years, and overnight success several years in the making. So I'm asking you to speculate a little bit. And it's related in what you talked about, the reason why I was able to move so quickly with with BUNDL with Medications℠ is because I spent so long building and making BUNDL successful as a financial platform I spent so long working on Inspire RX, to make them successful as a pharmacy pharmaceutical partnership platform. And so that made the BUNDL with Medications℠ seem like an overnight success. But I still feel like why didn't nobody do this sooner? I know, I'm asking you to speculate. Why do you think nobody's been able to pull this off yet?

Cheryl Campbell  17:40

You know, that's, I guess, you know, not wanting to put the work in not having the dynamic in the relationships we have not wanting to take on risk? I'm not sure. I mean, it is a good question. I think it's the same way that people say, Oh, we have a multi cycle at our practice, or, Oh, we do something like that. And it's not the same, it really takes and requires, first of all, buy in from our larger parent company of inception, who's made such a solid and amazing investment in our lines of business and the resources that we are able to have, through, you know, our talent, and our marketing departments are, you know, just just everybody's buy in knowing that this is such an important thing for our patients. I just think it's, you know, investing that and taking the time to build on it and, and taking the leaps and, you know, kind of going after it. I think people dabble in what we're sort of saying we're doing, you know, and they're they want it on offer, because of course, every practice wants to have as much on offer as they can. But it really does take a a sort of solid foundation of people that kind of understand these businesses, these streams of business to do this work. And I think that that's the leap that we're taking as

Karol Bonilla  18:54

Yeah, and I actually want to Yeah, I want to add to that, because I why no one has done it before is because it's not an easy task. It's not an easy task to have, you know, it's sometimes maybe there could be a set of treatments, but this is patient focus. What is the patient needing as far as treatment, what is the patient needing as far as medications, because if you want to do something like this are so many different variables to get it all together to gel for the benefit of the patient in the clinic is not easy, but fortunately enough, we're under the same umbrella where we can do this for the patient. That is not an easy task. 

Griffin Jones  19:32

The vertical integration piece is really something that you're starting to see different companies trying to get ahead of and yours is one of the earlier ones and these are the reasons why is because there's so many points on the patient journey and then if you want to positively impact them, you're gonna have to pull from different areas. So now let's start from the patient journey. I'm The patient, I've done my initial consultation, maybe have even done some of my testing and the physician is recommended an IVF cycle to me and now I am walking down the hall to the financial counselor, doc tells us, here's the treatment plan that you need and you're going to talk with Rick and Sally, our financial counselors, and they're going to tell you, give you some options of how you're going to pay for this. How do I, now where do I go from here?

Cheryl Campbell  20:34

Right. So the way that we have the process setup at our practices, it's at that FC consult, that they would be talking about BUNDL as an option in your journey. So whether the doctors test out that this is a good multi cycle patient or, or even if it's a cash pay patient, they get the entire suite of options for them and bundle would be included. So the lead generation of the referral will come over the same way from a clinic or again, people might see us on our webpage, people might call in because they heard about us from a fertility Facebook group. Either way, they're going to learn about BUNDL. And in that time, they're also going to learn that they've got this additional add on layer of the medication. So it's really at that the top of that conversation that we have all day long with patients however they move into BUNDL that we're going to talk to him about the medication option and it and the very simple straightforward way that if they for X amount of dollars, they can layer in their meds we will take care of the flow we will organize with the pharmacy. And then we aren't my team just coordinates with with inspired us to say, hey, you know this is going to be a meds patient. And it just kind of falls under the med, BUNDL Meds title, and we're kind of off and we will literally do the heavy lifting to make sure those meds are in the patient's hands when they need to be. And the other really beautiful thing, and this might speak to why people maybe don't do this, we're going to move with whatever we know this journey isn't linear all the time, right? There's twists, there's turns, especially with meds, you need more you need less you're not stemming, well, you need a different med, we're trying to go off of a very basic standard med protocol, which is pretty, pretty robust, I would say there's very few exceptions to what we're going to put under our meds program. And we're going to get you what you need when you need it. So in the 11th hour, if you need more follow stem, we're going to have it for you no questions asked, and I don't think many, I'm not sure many people trying to do something similar to this would be in that same, you know, we'd be thinking operationally like that. So I think we don't want to tie in REIs hands and we don't want to hold back on any treatment with a patient. So we'll, you know, it's we're still in our infancy with the program, but right now we believe in we're going to get the patients what they want, when they need it. And you know, that's that's a win back to the patient and to the into the respect and, and reputation of the program.

Griffin Jones  22:57

And so when the patient is having their prescription refilled, are they going through the BUNDL platform through the partner pharmacies? Are they ordering to the partner, pharmacies and partner pharmacies are sending the invoice to BUNDL? How does that work?

Cheryl Campbell  23:12

No, really, the flow on a regular BUNDL program is that my team will handle it once the patient is enrolled. And that could be either with or without meds. But once that happens, the the work then come becomes between my team and the clinical team. So we go back and forth authorizing cycles. And when cycles are authorized, we will authorize with the clinical teams to say put the meds, you know, this patient's pharmacy med piece, put that through bundle, they will do that work. So really, essentially, the patient's out of it at that point, they'll just see the med show up on their door. If the doctor then says listen, you need more follistim, the clinical team will say okay, this is a meds patient for BUNDL. So we're going to put that in under the BUNDL, and that flow, really for the most part. Now we know patients get nervous, and they oftentimes will stay involved and say My doctor said I needed more. And we'll say we know we saw that. Don't worry, it's it's fine. They can still have that communication with us. And we will assure them that we've got it, we see it, we're taking care of it. And it really just goes back and forth like that until the patient either finds success or moves through the rest of their benefits.

Griffin Jones  24:19

So even though I've had a couple of conversations with you all prior to this about how this works, it might be even easier than I thought it was so so it sounds like so in the clinical team is ordering the meds from the pharm, from the partner pharmacy, and there's billing it through BUNDL because that's already associated with it and then, so the patient doesn't have to call the pharmacy, get prescription filled, prescription filled, excuse me, okay, it's even it's even easier. Even though you've explained it to me, it's easy, it's even easier through the pay of it. Gotcha. That's it. That seems like almost as much of a benefit as the as the financial piece. Right? 

Cheryl Campbell  25:06

Right, exactly

Karol Bonilla  25:07

Right. Because it actually just to add to that, usually, when it goes to the pharmacy, then maybe the pharmacy doesn't contact within 48 or 72 hours, that could bring more anxiety to the patient. So because we have all the missing, we have all those pieces together, we have relationships, that patient gets contacted within 24 hours, for sure. And the patient doesn't have to worry anymore. So it is very easy for the patient and for clinicians as as well

Griffin Jones  25:36

And so what you're talking about Cheryl, with if they need more follistim, if they need more of something we're going to we're going to take care of it, that's preventing any latent hidden bills, right? Because that's already included with or with their BUNDL packet. So again, I'm coming at this from a reputation management standpoint, one of the biggest red areas in online reviews, is just a late bill, it doesn't matter if it's, you know, if it's a $275 ultrasound bill, or if it's a medication bill, when it comes just a little bit later. And maybe this is something okay, we've planned for this, I kind of had an idea with these medication costs where I didn't realize that the doctor had ordered when when he ordered the extra follistim, that that was going to end up on my bill later and it's a few hundred dollars more, sometimes thousands of dollars more, right? That drives people crazy, especially if they're still in the journey. And especially, even worse, though, if if they do have a failed cycle, and then that bill trickles in, it's like a dagger to the side.

Cheryl Campbell  26:51

Exactly. Exactly. The psychology that is so, so difficult. And so that's what we're avoiding. And this is what we do, even on the BUNDL piece, too. Right? We're it's so upfront you so know what you're getting from the minute that it happens, that there isn't going to be that shocker of you know, the late bill. And I think that I think that's, you know, that's absolutely what we're trying to avoid here. And I think that, you know, patients will will realize that and patients will understand that there isn't going to be Yeah, and people say this all the time. You know, when we talk about BUNDL we say we cover unlimited meds, people like Okay, so you do two, we're like, no, if you get four, you get four, if you get 10, you get 10, I think there was always so you say I can have whatever meds I want. So but there, you're gonna cap me at a certain amount, and we really, again, our rep, we want the product, we want people to understand that we we say what we mean, and we mean what we say and that is that this is going to we never want you to stop or halt or feel in any way that you're being nickeled and dimed. Or that there's anything that's going to stop the process. So we really, we really stand behind that. And these late, you know, there will be no late bill, there will be nothing that will come through that will, you know blindside any patients.

Griffin Jones  28:12

You said that there are very notable or there's very, very limited exception. Are there any? What medications specifically are included? And and what aren't things any worth? Worth noting that the what's included list as long as a lot longer. But are there any things worth noting on either side? 

Karol Bonilla  28:37

Sure, I can mention mentioned there's only two exceptions. There's a medication called omnitrope that can be prescribed. It's the off label medication. So that's not included in the BUNDL with Medications℠, and then there's a medication called Gonal-F. But we have a comparable brand to that that's also a reputable called follistim. So in essence is just one one item and then whatever the doctor deems necessary to prescribe for your treatment that's covered and store the refills as well. As Cheryl mentioned.

Griffin Jones  29:14

everything other than those two.

Karol Bonilla  29:15

Yes, sir. We want to make it easy.

Griffin Jones  29:19

So tell me about what clinics, which clinics are eligible for BUNDL with Medications℠?

Cheryl Campbell  29:27

So any clinics that partner with BUNDL will get the option to work with our meds piece of it. So you know we are within the inception clinics, we've got that all you know pretty much going but but BUNDL this year is in a major national march to sort of product try to partner with as many clinics as we can and that is in any pocket of the country and all in all over the geography and we want to try to be wherever we hear patients need us and so the minute that a clinic talks to bundle and wants to partner we absolutely may Get a point of talking about the fact that we've got this meds piece and for some new business currently, as we're talking to people, that's what's that's the kicker, that's what's thrilling limited at this point is that they're going to be able to have this medication offering. And thanks to Karol and her rockstar relationship with the pharmacy, she's able to identify, okay, within that market, let's sort out all the pharmacy piece for this practice. So if it's an Iowa and she can say, okay, well, in Iowa we've got, and Karol, you can speak more to this, but it's really nothing to operationalize and get that practice on the meds side of it, right. So it's just a matter of, you know, talking to their team. It's just, you know, one other layer on the onboarding side of things with practices, but everybody will have the option right when they partner

Karol Bonilla  30:45

Because as I mentioned, we have coverage nationwide, we have nice group of filling pharmacies. So wherever that clinic is located outside of, you know, of our network, we could provide services for as far as getting that patient that medication, it could either be picked up locally or shipped overnight. So we have coverage for any clinic anywhere in the US.

Griffin Jones  31:10

So if I'm in a market where BUNDL isn't yet so maybe BUNDL doesn't have clinic partner in Smithtown, USA, can I become a BUNDL partner? Do I have to be an inception family clinic, like a prelude clinic in order to be partner with BUNDL? 

Cheryl Campbell  31:34

No, you can just reach out to BUNDL and we will talk to you about joining our family. And it's very simple, you know, we'll talk about the the program itself and how it will fit your practice. And you know, we have a couple financial discussions and we can get you up and running and have an agreement over to you and start you tomorrow. And if and if that's largely driven off the fact that you want to offer this meds piece to patients, that's great. But again, you can offer the entire bundle part of it you can offer, you know, we've again, we've got our refund back program, we've got, you know, we've got the entire suite of offerings, and any practice can be a part of the BUNDL network. And we would love it, because we're looking to really expand because we talk to patients all the time in areas that unfortunately, we don't have a presence yet, or maybe a patient just really isn't willing to travel to. So we've really, really are hoping that something like the mid 30s, to will entice practices to to bring a multi cycle into their world, which is really what we want to be just that multi cycle option. It has many clinics as we can be in

Griffin Jones  32:40

Does that also include academic REI centers, or health systems that come in? There's large parts of the country where there isn't even like a private clinic? It might there might be one area that works in a division of a larger health system, for some states, especially like in the interior west and stuff. But even that, I mean, there might also be other markets where the biggest clinic or sometimes the only clinic group in town is in the university system. Can they still partner with bundle? 

Cheryl Campbell  33:09

They can. And it's interesting to say that we we we have approached some university systems most of the time, I think it's on their end, how they want to do it just there's nothing on the BUNDL side that we won't partner with you. But I think it's really more the guidelines of what the university system may dictate as far as bringing the multi cycle in. But we have no restriction on that. And we would love that because I know in some areas, that's kind of who you've got, right? I mean, and we would love to be able to serve an area, even if it's within the university system, but I think it's really more on what their guidelines are to that. But we'd love to still talk about it.


Griffin Jones  33:43

So there's the there's the the bundling of the medication costs, and you're having the ability to save patients money, it sounds like so there's the convenience piece. There's the predictability piece, but it sounds like you might even be saving patients money with the discounts can can you tell me about how that works, Karol?

Karol Bonilla  34:10

What due to our relationships with our partners and our pharmacy partners, that there is already a discount price set for all the medications. So the patient doesn't have to worry about, you know, how much is this? How much is that? All that is already taken care of? If that answers your question.

Griffin Jones  34:31

So then are there any additional benefits or incentives provided like like the personalized support, you talked about Karol, that sometimes people will call you and they'll ask for? They'll still want to know what what's going on with their medication, even though it's come through the clinical team? Is there any kind of personalized support that people that patients can get when they're working with BUNDL?

Karol Bonilla  34:58

Well, I think that Uh, with BUNDL, Cheryl can answer to that, but as far as the support that the patients will get when they get the BUNDL with Medications℠, because BUNDL could be just treatment or bundled with meds right. So if you're utilizing BUNDL with meds, you also get the added support from the filling pharmacy, they have also nurses, so they could do also medication teaching. So it's an added support to the clinician. And as we mentioned in and out of network, so any clinic, but actually once utilize BUNDL, and you know, and they have that partnership with BUNDL could take advantage of that, or filling pharmacy support, which I think is very helpful. Because in right now, in our day to day, we have so much going on, you know, with Mother Nature, a lot of clinicians don't have enough staff. So the added support is so beneficial for both the patient and the clinic.

Cheryl Campbell 35:55

Yeah, I mean, we've always said that with BUNDL, one of the things that we pride ourselves on and feel very good about is that we know these clinics are busy. BUNDL is is a small part of their day. But it's huge for our patients that they're getting these dedicated a dedicated team to really to really help them with their questions to get into so you know, clinics are busy. So maybe getting to the front desk getting that quote, that question answered isn't easy when they've got the BUNDL team as a part of their enrollment, and now they've got the meds team really, because even if there is an issue or a question, my team will work directly with Karol and Inspire RX and even has a line into the, you know, to the pharmacies, just to say so and so is a question, they're not really sure how to elevate it. Like, it's just, it's just that getting people where they need to be and we know and as an ex patient myself, you just it's that frustration where you feel where do I turn, but when you so the more again, it comes back to what I said at the top, the more you're able to pull all these pieces and parts in where a patient can now say, Oh, I've got BUNDL, and I've got meds, oh I can talk to BUNDL. I'm gonna talk to BUNDL about what I have a million questions, but I can now talk to BUNDL and I've talked to my pharmacy, talk to my doctor, you know, and then they can just focus on really the clinical piece of it. But I think that it's it's trying to, we talked to so many patients that really are sort of most of the time in their journey, just saying, who do I talk to about all this stuff. And I think having this these dedicated teams, and another reason why we're doing this, we're doing it well, because we know whether we're teams dedicated to getting this this done for patients,

Griffin Jones  37:35

That talks about the reputation management side where it's the client, it was it's where it's the patient, voicing their frustration, if in when they don't get that communication, and that happens all the time. But then we're also on the other side, where we listen to fertility clinics, phone calls, and we check your call volume, we look at what the wait time is we look at how many calls go to voicemail how many calls hang up before that their answer because they're on the phone tree. And it's always a problem. And very often it's a problem because there's a limited staff on the the call center team or many fertility centers don't even have a call center, they have the front desk for a number of different things, and they can't get to enough new patients or they can't get to existing because people are calling back for for things. And this is one of the areas that people are calling for information for and if they can call you instead of the clinic. That's one less thing that the clinic has to have tying up their, their whole phone tree and their whole their whole process, which drives that patient crazy. But it also it's also really hard for the front desk team that the clinical team. Cheryl, I'm just curious because you were a patient and you've spent so many, so much time working with patients on a customer service side. Nowadays how much of your time are you interacting with your quote unquote customers but the but patients versus how much time are you managing and the other folks that do that? How often are you working with patients nowadays?

Cheryl Campbell  39:22

Yeah, not as much I wish more I'll be honest, you know, since I transitioned from sort of having helped stand up BUNDL from the operational side and now moving into the director side, I don't get to talk to patients but every now and then because our programs are three years long and we started in 2020, most of our patients that I started out with earlier kind of still cycling in one way or another many of them so I love when they come back and many do just to sort of say I have a question and I remember I talked to Cheryl a year ago and I'd love to talk to her so I love that and then now and if I can just make say this a lot of patients are finding success and so we hear about pregnancies and we hear about you know, the babies that are, that are BUNDL babies that are being delivered. And that is super exciting. So I love to hear that, because that's a real full circle moment for me having been part of the very beginning of the program, but I think I'm spending the larger majority of my time managing and kind of getting everybody down the lanes that they need, and making sure that my team is feeling well resourced, and and you know, informed because they, they have a lot throwing at them every now and then like, we do little changes to BUNDL, and then we bring the meds piece in, and then you know, so that's been a lot, it's been a lot of changes, but you know, and then we've got a whole network, and we never, we always say we never are done. So even when you partner with us, and even a very, like our own family clinics, inception clinics, right, of which there are many, and we've had very long standing relationships, there's always a tweak, there's always a process. Look, there's always something that might break down or a patient or will, you know, maybe a doctor isn't feeling as good about it at one point or another, or they're hearing something from a patient. So we're always in process improvement, and what can we do most so it's never sort of, oh you're in BUNDL and now you know, good, you're done, you're on boarded. That's it. So there's a lot of the piece of keeping, you know, all of this moving. And this is what we're going to find in this program as well. Right? We're sort of early, thoroughly early days. But but like we do with all of it, and I'm sure Karol does it on her piece as well. You're just always looking for how can we do better? How can we improve, maybe we get rid of something that just isn't working and people don't feel good about. And that's coming from clinicians. It's coming from doctors, it's coming from our patients, it's coming from our our executive team and our marketing, and it's all a buy in. So there's always a lot to do because we're sort of still a little startup, we're sort of still the baby of the family and the inception world BUNDL. But yeah, we're we're making major strides, though. And this is just another way of doing it.

Griffin Jones  41:54

Do you feel like were you on the, when you started to launch BUNDL with Medications℠, did you get to be on any of those calls with with patients or when you when you started to be to tell patients? This is something we can offer you now, tell me about that? What like I'm interested in their reaction when it went for it. Because you started, you started that splash at National Infertility Awareness Week, and then, you know, so this is something that they haven't ever been able to get before. You're now managing the people that are helping them in many cases. But did you get to be privy to any of those reactions?

Cheryl Campbell  42:35

I got a few of them. But most of it is feedback from my advocates that are talking with patients. And I think the firt the overriding comment kind of was like, Oh, finally, that's great, thank goodness, or, oh, gosh, I'm scrambling to start, can I still get into the med side of it. But you know, like, there, people are sort of like, wait a minute, this has changed my whole mindset way I want to do meds with you. So we we sort of have, that's another thing we've done things we move very quickly. And thanks to Karol's team as well, we can move a patient very fast, even if they've only just found out about meds, and they're just ready to start, we can get it done quickly. Because we know meds need to get ordered and get to a patient but we can move fast. So I think there was a general sense of oh, this is great. Now, there's always always the patients that want to take a beat and say, okay, I understand what you're saying, I want to layer this in. But I might need a little bit more time because now this is an extra bit of money on top. And okay, let me so it's it's paused some people to kind of really consider it. One thing that it's really benefited from which we've heard from patients, especially when patients need loans, and we work with the top fertility lenders, right, some of the pain point for a patient is what we alluded to before that unknown Oh my gonna get slammed with this cost. And that costs when you have one bite at the apple to get your loan, and especially if patients maybe have never had an experience of having to take out a loan, or certainly something that's large, you want to be all in on what that number is, right? Because if you're going to have one shot to go through all the due diligence of getting a loan, you want to know what it is. And so when you're blindsided by that extra five, that extra 10, when you know upfront, here's my program fee, here's what I'm going to owe on my meds. Here's maybe the little bit that I might owe to my clinic. I'm all in I'm going to go for that number. And I'm going to see what I can get that is helping with the lending conversation. And I think that now also, even though our lenders multi disperse really helpful that they can now bring the whole piece over to bundle and just say write all in on the program and the medication. Here's your patient's financial piece of it, and it's done. And a patient usually is it's another layer. Yeah, it's another layer of chasing up the loan and where does this piece go and where did that this is now another way that we've consolidated and helped not only the patient, but you know, even with our relationships with our lenders, it's increased that that's level a little bit better as well.

Griffin Jones  45:02

It sucks that patients have to take out a loan like this. Like, it's almost like another little mortgage on it. Yeah, it can be a big be a big car loan, it sucks, that has to happen. But it forces me to, in some cases, in some sense, compare it to a mortgage. And if you, when you get a mortgage, you're also factoring in the closing costs. Again, not it's not just what this what this person has listed the house for. It's also all of the other closing costs that go into purchasing the house. And it's like, you get a home inspection. So you want to know if there's something that is going to be immediate, like if it's, if I'm buying a $400,000 house, and I know that there's going to that there's repairs to the furnace that are necessary. So that's your like, that's your medications, like, okay, I know that the house isn't just $400,000. And that because I know that I'm buying it, where it's going to require these repairs to the furnace, or the plumbing or the electric. And that's what I have to plan for in the total. So I've always thought when I think of BUNDL is like, okay, it's planning for that. But that impacts the the loan to what, what you're, what you're taking out for, for the loan. So do people are people in, and, we touched on this a bit when we when you were on before, Cheryl we were talking about the BUNDL, but do patients interface with the loan companies on on their own, and then get support through BUNDL, or it's all through BUNDL, and BUNDL is dealing with the loan companies.

Cheryl Campbell  46:49

I think what we have managed to do is bring patients right up to that juncture where they're ready to talk to that loan representative. Because at that point, you know, they have to provide the personal information, and they have to kind of do that piece of it, but we are with them right up. And again, like I said, we have a lot of patients have never, they've never gone through a loan process before, you know, getting bank statements, and you know, so we lead the right up to that point. And, and our lenders are so good. And gosh, lending. I mean, I think that, like I said, even on my own journey, like I don't even know if anybody knew what a fertility lending piece looked like. But it's so wonderful the way that lenders are aware of, this isn't, you're not taking out money for a, you know, a car or a condo, right, this is a they know how stressed and difficult this is at the point at which they're talking to these patients. So our lenders are so wonderful with the way and the offerings that they have a lot of lenders even offer, you know, special little help for patients like if they need to know how how to do a trigger shot, or how to, you know, that's just a plug for our lenders, because they're just they're listening to right and they're trying to meet patients where they are because it's a kind of daunting process BUNDL will help you get right up to the point where you're talking to that lender, and then they do their due diligence with the lender, get the okay for the loan, and then we pick up from there, we get the funding in, we work all that out all the payment. And then of course, and I want to make sure that this is understood, we have a refund back program, right. So with BUNDL, if you qualify, just like under our regular BUNDL program, and you go through all the program and you don't take a baby home, you get 100% of your money back, that's our BUNDL guard 100% money back. Now with meds, if you buy meds on top of that program, and you do not again, you're not seeing success in that program, after all your services, you're going to get 100% of your meds money back as well. So our guarantee that we have built with this program is going to extend into the meds piece. So that is really huge for patients. And I think that they've got even more peace of mind, even with the meds in there. We're going to give 100% of that back. So that's, I want to make sure that I understand that so those that qualify for you get 100% back and if they do the meds piece, and they qualify for BUNDL guard that that's going to, they're also going to get the meds but it's not like oh, I can qualify for BUNDL guard over here. And not quite, but maybe not qualify new BUNDL meds piece.  No, if you've added the meds onto your BUNDL guard and you've gone through all your services without taking the baby home, that meds piece is a part of that 100% back so it's the full amount back to you. So that is even in a bigger peace of mind for patients, I think as they enter into the BUNDL guard.

Karol Bonilla  49:38

That actually answers your previous question, Griffin. Why no one has done this. This is why no one's going to do that. No one. 

Cheryl Campbell  49:46

It's the risk, right?


Karol Bonilla  49:48

Yes, that, that is unheard of. So that's why no one can do it.


Griffin Jones  49:55

Yeah, that's that's a pretty big logistical hill to climb. Karol, how do you get the, how do you, this is maybe a little bit more Inspired than BUNDL because we're talking about the meds piece, it's relevant to outcomes back to the patients in the clinics, how, how do you interface with the pharmacies in such a way where you can make sure that okay everything except for Gonal-F and Omnitrope, we were gonna get it for you. We're gonna get it for you on time. That's it's a big logistical lift, and you've got more than one partner. So that's probably what helps you is you got multiple partners. But how does that that pharmacy logistics work?

Karol Bonilla  50:39

Well, it's having conversations with each and every one about our new offering. And then being able to say, yes, we want to be part of this. They're part of our network as far, our Inspire RX network of filling pharmacies, so they know what this meets overall. So getting them on board was an easy task. But of course, it's a conversation with each one. And there was really not much questions asked is just what is necessary. You know, and, you know, we're gonna get it done, because we have that partnership. So it wasn't a difficult task and that end because of our partnerships.

Griffin Jones  51:20

How many pharmacies are partners within Inspired RX?

Karol Bonilla  51:23

Currently, we have seven filling pharmacies,

Griffin Jones  51:27

And are all seven Inspire RX partners? Part of the BUNDL with Medications℠? 

Karol Bonilla  51:34

Yes, sir. All of them.

Griffin Jones  51:37

So that they, they've all come over and Cheryl, when you said that the programs last for, they're three years. So that if they add on BUNDL with Medications℠ in the beginning, that's, that's for the three year duration as well?

Cheryl Campbell  51:54

Yes. Yeah. 


Griffin Jones  51:55

So there's, it's not like the meds piece lasts for a time?

Cheryl Campbell  51:59

No, it's going to be covered over the Yeah, it's going to but you know, again, time knowing that majority of patients will probably finished their programs within, you know, 10-11 months, that's really our average. But we you know, you never know life takes over maybe a patient does a cycle, and they need a break or something happens in life. Maybe there's a personal reason, a surgery, if they are putting that off, and then they're going to revisit, let's say cycle two, but they've bought meds that that those meds are going to be available when they're ready to pick up on the next time they go into service. So that's, there's no, I'm glad that you asked that question. Because I think that people may think, oh, gosh, I know the program's 36 months, but there must be a cap on meds. And we're saying no, because again, even if you take that break, and then you pick up 8, 9, 10 months later, that that meds is good, you know, the doctor will tell you what your med is going to be and we'll put it through and then that's it. 

Karol Bonilla  52:54

Right, life happens. So that's part yeah.

Griffin Jones  52:58

So the whole that's the whole point of BUNDL, it seems like to me like it keeps coming I like the discounts are important and they're meaningful and I get how you're saving people money but it seems to me like just that the peace of mind maybe maybe that's just me, maybe some other people would would prioritize the discounts higher and, and the peace of mind is the benefit at whereas I just see like, it takes out so much of the worry and it's like this is what it's going to be I've got three years to do this. So that not, if life happened, when life happens at some point all of these contingencies are accounted for now I'm not asking either of you to you know to show the cards too much or but I just every time I talk to you I could see okay, something else like something else is coming from BUNDL because this is kind of the ethos of BUNDL it's it's our job is to streamline all of these financial hiccups for for patients, make it easier for them to pay for, it make it easier for them to know what to pay for. You know, when I first talked with you, I didn't even ask about medications and and and I could just see that it's not just about the services that BUNDL is providing now but it kind of being committed to this ethos of this is our this is what our vertical is it's it's reducing this variability for patients and giving them predictability. So I feel like I feel like you've got more in your roadmap, and you don't have to share any you don't have to share any secret sauce. But can you kind of just tell us what you're paying attention to in patients needs that are going to have to be solved for some day?

Cheryl Campbell  54:45

Hmm, that's a good one. I can because I think in the immediate my whole feeling is that what what what brings me down or bums me out is when I can't get to a patient that needs me in a market that I'm just not there. Right? And there, they are just so elated over the thought of BUNDL and what they need. Because look, I mean, I think, you know, the percentages still aren't getting great with one cycle success. So multi cycle, you know, and we and again, we're a cash pay program and you know, we can even do programs for minimally insured, and we are, you know, insurance is getting a little better, but it's still, you know, not 100% there. And, you know, I always say this, like, this is a juncture in the year where people have maxed out on fertility benefits, this is a time where we talk to a lot of patients, because they're they don't have any more coverage. Now they need a BUNDL, and they're not and time is ticking, right? They're still at that 36, 37, 38. Nobody wants to hear oh, you are running out of time when you're 36. But you know, that's the reality is that this journey just doesn't stop. So, you know, I just feel like, my biggest immediate focus is how can we continue to help people in places that we are not, but we are always listening to our patients and trying to hear about the what's next? And what else would you like, and I can't really say for sure what that next top thing is, but you know, we're, we're going to be there when we know it. And we're going to always keep our ear to the ground. And I think we're off to an amazing start with what we're doing with BUNDL, what were our relationships are with our partners, like I said, the resources that come out of of inception for us, there is a real focus, because we believe in what we're doing. And I think it's really helping patients at a really difficult time.

Griffin Jones  56:38

I hope that geographical expansion does come from the patients that are that are really asking for it in other areas be and it stinks that they have to but and I'm not comparing BUNDL to Uber, but I just remember how Uber started in the Bay Area. And then they went to a couple of major cities, and then they went to smaller cities. Well, for whatever reason, New York State was the last place to get Uber except they made a little deal with New York City that New York City could get it earlier. And it was really some convoluted political thing. But it ended up being coming a point where the people in the cities of upstate New York, Buffalo, Rochester were like, Why don't we have this? And why? Why is that anywhere else? I go, I can have this privilege. And yeah, and and then and then I come back and I don't get to have it. And it goes almost it goes from being, you know, a nice to have to a must have. And when you start to see everybody like why did they get it over here? And I don't say I hope that that's part of what drives the the geographical expansion. What haven't I asked you about BUNDL with Medications℠ that that I should have, or how would you like to conclude with our audience?

Karol Bonilla  57:59

I think you you ask everything because you know, I think what's important is who can we service? Who can join who could take advantage that was answered? Anyone can take advantage of this? You could get pretty much all your you answer over the right questions, I think. So, 

Cheryl Campbell  58:16

Yeah. There's no qualification, per se. You know, we just want it to be there. As another option. I will say this, you know, there's nothing harder than when patients as much as being thrown at them in this right. They want to know, they want options. They want to know that you think enough about the fact that you know, they're going through something difficult that you want to say, look, here's something that might help on the multi cycle side, but the financial piece, here's a lender that we think might help you. Here's a grant program that we think this is what we do at BUNDL, we give the information so that everyone can make their most informed decision and put their fertility dollars where they know they need to go because, you know, some people have just small pot and that one shot and they want because there is nothing worse than a patient saying I never knew about you. I never knew about these options. And now I can't go back and get another loan. And I had a failed cycle. And I mean, that is the most heartbreaking part of it. We know that these are big numbers, right? We know it's expensive. We were still keeping an eye on the best that we can always do on that front. But I think that we can never assume that someone doesn't want to know, a piece of information. Oh, you know, you're probably okay with one cycle. Maybe you don't need to know about the multi cycle options. It's heartbreaking when people don't know. So I think the biggest thing is just making sure that patients are informed and have all the pieces and parts and that comes everywhere from the doctor conversation straight through the FC's than when they cut over to us. And then when they're in their mom groups, and then when you know they just we just want the word to be out there that people should have a conversation and really get all their information before they move forward. And then, you know, see, see what happens.

Karol Bonilla  1:00:08

And you know what Griffin, I think there's something that I do want to add, just based on my experience in the fertility space is that with BUNDL and BUNDL with Medications℠, we're most definitely patient focus. And you can see that through our actions with the type of offering that that we have. So we're definitely patient focused. That's what I that's what I would like to end it with.

Griffin Jones  1:00:32

I'll end it with a lot of people say that a lot of people say they're patient focused, and there's, there's varying degrees of what that that is and, and it will like when you're talking about, like, we're going to make it right for the patient, we're going to, we're going to help them if they need more meds we're gonna get for them. A lot of times people will say that, and then it's except a, b, and c. And a long disclaimer, and, and I've never been in the BUNDL office, I've never I've never, I've never shadowed you both and stood over your desk. I've never been a patient going through this and have to. So I can't speak from the total global experience of it. But I can say, from getting to know both of you from talking to your colleagues, some of whom have also been patients that when I when when I hear you say that, I really believe yes. I really believe what what your commitment is from, from your team. So good on inception, leadership for letting you all have this autonomy and build this and because, again, I might not know from all of the other things, but I'm telling, like, I smell real. I know what not real smells like. And right now I'm smelling real and I have every time that I've had you on and I've gotten a chance to talk to you. So I look forward to having you on again. And thanks for coming back to this conversation.

Karol Bonilla  1:01:58

Thank you.

Cheryl Campbell  1:01:59

Thanks, Griffin. Appreciate it.

Sponsor  1:02:02

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients. Please visit www.bundlfertility.com/medications-cost That's bundlfertility.com/medications-cost. Today's episode is paid content from our feature sponsor who helps Inside Reproductive Health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health

191 3 ways to increase fertility center revenue with genomics featuring Dr. Mili Thakur

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Should you consider integrating an in-house genetics counselor into your practice?

Today’s guest, Dr. Mili Thakur, makes her case on the future of genomics and its place in the REI medicine space. She walks us through how an in-house genetic counselor can boost practice revenue and optimize patient retention.

Tune in as Dr. Thakur gives us insights into:

  • Her 3-point business plan showcasing the importance of genomics integration into REI practices

  • The number of cases she believes warrants an in-house genetics counselor [It’s not as high as you think]

  • Why Carrier Screenings matter [And her criteria on how she vets companies]

  • The future of Genomics [And why it’s the biggest investment opportunity even beyond the infertility space]

  • And more…

Dr. Mili Thakur:
LinkedIn
Genome Ally, website coming in May

Transcript

Dr. Mili Thakur  00:00

I think it would be dependent on the total volume that you're able to bring in to the practice. I would say if a doc is seeing about like 10 to 12 some of 15 new cases in a week, you know, there's going to be at least two or three of them that are genetics or their hidden genetics like they're not obviously I but like recurrent pregnancy loss if you're seeing five or six recurrent pregnancy loss patients in a in a week. You know, in about two weeks, you're gonna have a PG DSR case.


Sponsor  00:33

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Contact bundle at bundlfertility.com. That's bundlfertility.com/contact-bundl. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest appearance is not an endorsement of the advertiser.

Griffin Jones  01:27

A call for action amidst the turmoil of the reproductive genetics field now I didn't write that but my guest did her name is Dr. Mili Thakur. Dr. Thakur is double train. She was the first fellow to graduate from an ABOG ACMG combined fellowship in reproductive endocrinology and infertility and medical genetics. She did that in 2017. From Wayne State when she left fellowship and join private practice in Grand Rapids, Michigan, she made a business plan she made a business case for why they needed an in house genetics counselor at a four Rei practice in not a very big market. We go through that business plan having an in house genetic counselor and having genomics be a part of the REI practice today, Dr. Thakur supports that plan with three different points. First is the revenue that's generated downstream from genetic counseling, the additional cycles, the testing storage that might be necessary. Second is patient retention. Dr. Thakur argues that if patients really struggling with a genetic abnormality and you're the one that finds it, they're going to stick with you. Third is donor IVF cycles if you can prove that they're necessary from finding abnormalities then that patients going to need donor cycles. I pressed Dr. Thakur on why genomics is so valuable to the practice why it's so valuable to the patients as well. And I come across a point where her background might give her an insight that is not at odds with you potentially and that has to do with carrier screening and the variance in the quality of panels. I've got the impression from my nine non scientific polling of many of you that it doesn't really matter who does your carrier screening. There's a dozen or so companies out there. Many of you have told me it's one or the other doesn't matter too much. Being a geneticist, Dr. Thakur has a different opinion. Dr. Thakur thinks the carrier screener does really matter. And she shares her criteria for how she and her genetic counselor that carrier screening companies criteria such as actionable conditions versus non actionable conditions, and they have to be actionable criteria of the curation of data that labs have to be able to curate that data and I pushed afterthought core on how scalable these revenue upsides are for fertility networks that might be trying to cut the lowest possible deal with a carrier screening company that leads us to the question does someone with a genetics background have to be a part of the governance of a fertility network the same way a chief medical officer and a chief scientific officer are asked Dr. Thakur for a ballpark what number of genetics cases make sense to have one full time in house genetics counselor turns out not that many in her view, Dr. Thakur surmises, we have 10 to 12 new patients a week two or three of them might very well be genetics cases, she gives the caveat that you have to be looking for that which is at the crux of the whole conversation. And she shares more detail about that we talked about the future of genomics and art and how that might become so much bigger of a marketplace than the infertility segment alone. Dr. Thakur thinks that genetics is far and away the biggest investment opportunity in art. So I asked her why the heck doesn't it look like that now with genetics companies closing their fertility divisions? Her answer made sense to me. I want to see if it makes sense to you. Finally, Dr. Thakur talks about her new venture genome ally that she's beginning to prove concept for and bootstrapping my thumb to the wind test of all of this is that we are in an atypical role for genetics in the fertility field and then it's going to come roaring back my perspective. Isn't that interesting? I think Dr. Thakur is more so I hope you agree and enjoy this episode. Dr. Thakur, Mili, welcome to Inside Reproductive Health.


Dr. Mili Thakur  04:57

Thank you Griffin for having me. It's a privilege to connect to your audience.


Griffin Jones  05:01

It's a pleasure to have you on you've become a bit of a voice for genomics in the fertility center, I saw that you were quoted in an article that one of our journalists wrote a few months back about the changing business landscape of genetic testing and genetic counseling. And then I've seen you at a few talks throughout the field. And so let's start there, maybe how did you become a champion for genomics inside the fertility practice? 


Dr. Mili Thakur  05:34

So Griffin, I am a combined reproductive endocrinologist and a geneticist, which is great privilege that I had off training that way. So I am a OB GYN, I always took care of women I trained back in India did a residency there then came to Wayne State in Detroit did a residency and fellowship here. And that phenol shear force, namely, for me, was an opportunity to combine both the fields. So I'm the first fellow to graduate from a combined reproductive endocrinology and infertility and medical genetics fellowship. And that's what got me interested because I had a different perspective of both the fields combined together. So even though I trained in traditional genetics, and I know how to do cancer genetics, and pediatric genetics, and, you know, genetics for neurological conditions, and I trained for it with my fellowship, I specialized in reproductive genetics. And because I'm a reproductive endocrinologist, I do IVF every day, that's part of my, my practice, I take care of patients from the infertility struggles, and help them with both of these things combined together and merge, which is an amazing opportunity.


Griffin Jones  06:48

What's his specific use in your own practice in the way that you practice that you feel that you've benefited from having that genetics part of the or that genetics fellowship, that you feel that you wouldn't have been able to implement in your own practice of REI had you not had that fellowship?


Dr. Mili Thakur  07:09

So I think all reproductive endocrinologist or REIs do genetics as part of their job. But the advantage that I had from this additional training was that I was able to be well versed in the lab aspect of it, the moleculer aspect of it. So I understand the test, I just don't offer the test, I understand what's the science behind those tests. And I am also able to take care of like, complex situations that involve genetics. So because of our training, you know, we, during my training, I took care of like newborns who were diagnosed by the newborn screening program in the state of Michigan. So I've seen those conditions firsthand, and how they affect children. So when a couple comes back to us, saying that they have a child that's affected, you know, I've seen the other aspect of it. So the combined fellowship helped me hone into a specific area. So it's not difficult for an area to take care of genetics on a day to day basis, they do it all the time that traditionally it's been done. It's just I've been able to cater to a niche of patients, because I understand that complexity. And it's easy for me to say, you know, what needs to be done here and how to select the test. So there is this specialization that has developed based on that


Griffin Jones  08:36

I won't go too deep into the clinical, because it's not a clinical show is a business show, which is what I'm more qualified to talk about. But I am curious when you're talking about not just being able to read the test results, but to understand the science behind the test results. Can you think of an instance where it was really paramount that you knew the science behind those test results, as opposed to being able to just read the test results to any does any one instance come to mind?


Dr. Mili Thakur  09:04

So one of the common tests that all are used, and I know your audience is primarily people working in the reproductive medicine field is a carrier screening. So preconception carrier screening is a common test, it's been given by different companies. So there's like more than about 10 to 12 companies that offer that test, it may be even more than that. So each one of those companies uses a technology called next gen sequencing. And each one of those companies offers a panel of tests and that panel can range between sometimes 23 conditions to like now 600 700 conditions. So what advantage that that additional testing brought for anybody working in the field of reproductive genetics is that I understand carrier screening testing from a different angle sometimes i i unlike colleagues like myself, would be able to understand more than the medical representative or the salesperson who's coming to sell the test. So for an example, like for cystic fibrosis, you know when for cystic fibrosis is a common condition that we are carriers of that tests can be done by next gen sequencing, most labs are up to par and sequencing that gene and like looking at different spots on there. But then when a certain type of mutation comes through, there is another additional testing called five t testing. So to be able to ask the medical rep to say, do you do five t testing? Is there a reflex that we can do if needed? Same thing for like fragile X? Do you do AGG repeats? And how is your curation of radiant? How often do you guys look back? So we have another stringent layer that I'm putting any tests that I am wearing for my patients through? So it helps me serve my patients better? Because I have an understanding of what they're doing behind the scenes? How is that report being signed off? You know, what are the things that they are not reporting out, because they're not reporting out the whole gene to say, and so in genetics, you know, our colleagues in genetics will relate to this much more, we don't say, hh, you're negative for the condition, we say there is a risk reduction. So you being a carrier, based on an ethnic background is a certain number. So say one in 30, after the test, that risk slows down to being one in 10,000. But it's never going to be negative, because the science hasn't advanced to the point where they can look at the whole gene completely. So by knowing that back end workflow, and what is out there, I can challenge them and have them give us the best possible test.


Griffin Jones  11:47

So you can vet the tests better than you could if you didn't have this background, and you mentioned a couple of different applications for it. So you're ultimately getting more productivity from the test, you're, you're getting better results from the test, is it also to vet so are some tests? Did they have features that are unnecessary that are, that people are paying for? Is that part of the vetting or not as much?


Dr. Mili Thakur  12:12

It is. So basically, what we do is like for each of the patients that comes to me, especially with complicated, complex genetic history, we are able to find the right test for them. And then kind of streamlining the cost of it as well. So as, as one of your previous guests on the show, Dr. Arredondo, Paco, always says, you know, we have to cut the frills out of the thing. So sometimes with these complicated histories, you know, because we are in such a busy practice, you know, you might order five tests, but then if you had that understanding of the test, you would be able to go straight to the test that's right for that family, and be able to serve them. So a quick example is, I had a patient who will their their dad had a condition and five of the boys, you know, three out of those five had a certain condition where their hair nails and skin was abnormal. They now wanted to do IVF. And they wanted to do IVF, because they didn't know that genetic mutation in their family, their dad and mom had gone through some genetic testing 20 years ago, they didn't know you know what the mutation was, at that point, they just wanted to do IVF with PGT A and select for boy embryos, they said, We don't know what's affecting our family, three out of the five boys are affected by this condition, we don't look good, right? So let's just have a boy so at least he wouldn't be bullied in school or have issues there. And because now they were coming to see me and times have changed. Now I could look at him and say you have some form of ectodermal dysplasia, there is a panel available for it. And then we worked with the family and with our colleagues in genetics at a local hospital, called them the right test, we were able to identify a variant now variant of uncertain significance means that you know, we don't know if it's really the causing disease because it had never been reported before. We had a family where three boys who are affected to were not affected, we were able to segregate the variant test everybody in the family. And then not only that person, but we were able to identify a novel variant. It's never been reported. This is the first family in the entire world to report with that condition. And then that person and his brother went through IVF for selecting embryos that are disease free, they were able to transfer all different genders that they wanted to and also have a healthy child for two of the brothers that are affected. And so coming back to your point of like the business aspect of it, had I just gone and done IVF for pcta saying okay, we can't find the answer for you. We would have just finished up with one cycle, the patient wouldn't have been served to the best interest because their mystery would not have been solved their story would still be like, we don't know what's affecting the children in our family, right. But now with this additional testing, our practice, my practice got not just one, but multiple IVF cycles, because they were searching for the right embryos, they're coming again for another transfer each one of those families has had done now for transfers, right, they have two children each. So it's a long term relationship that you build. And the revenue generated from all of that is what then justifies that process. So I spend extra time because I'm extra trained and like, I have this additional training. So I spend extra time but then I make up for my time with that additional revenue that I generate from these cases. So the biggest thing that's driving us is patient benefit. Now they have an answer. Now they have a healthy family. But it took extra effort, it took some time to get to that answer. And you know, we were able to solve that case. So that additional piece is what makes this model sustainable. 


Griffin Jones  16:16

So we ventured into PG ta but back to carrier screening for a second, I had always gotten the impression from doctors that they didn't really care which carrier screening provider, they chose that many of them do care who they use for PGT A but for carrier screening, I'd always gotten the impression that doctors feel like that it's a commodity, is that less so in your view? Is it? Is it not as much of a commodity as doctors think it might be? And that there's a bigger difference between carrier screening providers?


Dr. Mili Thakur  16:45

Yeah, so actually, for from my perspective, and many of my colleagues in genetics, we are extremely thorough and careful in the products that we select, we consider them as products. And like any other thing that a clinician would be offering to their patients, you know, you have to understand what they are doing. Because the main things to consider is one, are there actionable conditions on their panel. And there are conditions that are not actionable, there are very, very rare conditions on there, and they are going to be reporting those out, you would have a very high positive rate, and you will have to deal with the back end of it. So first should be actionable conditions. Like I don't want a panel that has an MTHFR on it. MTHFR is a genetic change. That's very, very common. So I don't want a panel that has that change, because it doesn't change what I do clinically. And it kind of raises red flags for no reason. The second thing is how thorough is reporting, you know, of the different genes that they're doing? And then also about how is the curation? So some of the our viewers will, you know, be able to understand this? Well, it's like these changes that are being reported, some of them are very new, and they are being reported as variants of uncertain significance. We don't know if they're gonna cause disease or not. But because the science is advancing so fast, all of these labs have to curate, they have to keep every six months look back into the database and say, okay, now, is this mutation something that's deleterious? is causing disease or not? Is it something that's going to be causing problems? So if a lab does not curate their data every so often, then you're going to have gaps in there. And then in prenatal testing, or in preconception testing, if a variant is reclassified? Is the lab going to let us know? Because you know, for future, like if this couple is going to have situations where a couple came to us for second opinion, because despite a normal carrier screen, they had an affected baby, because they had a variant of uncertain significance, which was not reported out. So we went back to the lab, and we wanted them to look back at the data, reclassify the variant, and that's why, you know, it's important for busy clinicians, REI providers, doing high volume IVF, all of these networks, to consider working with somebody who's, who can take care of those extra genetic needs, like when you're picking up product, no matter which genetic product you're using. So some of the products that we use, one of them is carrier screening, another one is stereotyping. Another one is products of conception screening. PGT is another product, you have to know what you're offering to your patient. What are the gaps there and challenges there so you can counsel them appropriately. There are some companies that are not reporting out HCG repeats and FMR gene. So if you've got somebody in that certain situation, then you will have to request it extra versus there are some companies that will do the FMR gene, and if they found a certain thing, they will do the AGG repeats. So when the results come to you, you're able to say, yeah, this is something that's actionable or not actionable. So the complexity of it is being lost because of the volume terrible providers are seeing and you know, you were at some recent conferences, there is this shortage of REIs, like all of us are doing a lot of cycles. So in all of that, the piece that a single test is playing is so small that it can be overlooked. And you know, things can fall through the cracks. So there has to be safeguards put in place of like, okay, which, which tests are we doing, if we said to a patient, you are negative. And sometimes, you know, in practices that don't have that expertise, or leverage, a nurse might give out test results. And she might say, Oh, you're negative, and the patient who doesn't know the science of it just thinks, oh, they're negative for cystic fibrosis, but that's not the case, do the test that, that your risk of being a carrier has now been reduced. And now, you know, your partner has been tested and their risk is reduced. That means there is still a likelihood very, very small, though, that something could happen to a child, you know, so the understanding of it is a little bit different. Our viewpoint is different, basically. So I would read, I always read the test, I understand I sit down with the reps, you know, I would look at all the information before I will select the test.


Griffin Jones  21:33

With regard to understanding I read your bio, a little bit of it before we sat down for our interview here. And it seemed that your center, the your fertility center, the Center in Grand Rapids hired an in house genetic counselor in 2017. Is that right?


Dr. Mili Thakur  21:50

Yeah. Yeah. So I started out of my fellowship in 2017. So as soon as I landed the job, you know, I wanted to have an in house genetic counselor.


Griffin Jones  21:59

Tell me about how you made that case at that time, because at that time, you're an independent center. So now you're Ovation now US Fertility at least on the lab side of things, but the at that time, you were completely independently owned fertility center, is that right? 


Dr. Mili Thakur  22:14

Yeah. 


Griffin Jones  22:15

And Grand Rapids is not a huge market. And so how did you make that case that, that you needed an in house genetic counselor in the practice?


Dr. Mili Thakur  22:26

So I had to write a business plan. So like anything else, we wrote a business plan. And, you know, I had a strategy of how to make it financially viable for any practice to embrace a new set of paradigm, you know, you have to make the case of how we are going to make it financially viable. And the way we did it, and one of your previous guests, Amber gala talked about it, you have to work with whatever is happening in that state. So in some states, genetic counselors are able to bill at the time, you know, in Michigan, genetic counselors, were not able to build for it. So the way I did the things was one, in my mind, you drag generate revenue downstream from the genetic counseling. So if you are able to one, number one is engaged the patient, if somebody comes to you, and you're able to provide the right service and engage them, you're gonna have a better chance of them going through a complicated treatment. That's number one. The second thing is patient retention. If you've had somebody coming in for failed cycles, and now you're able to do some genetic tests, you find the abnormality, they will, the patient is not going anywhere else, no matter how long it takes. The third thing is because of all the support that you have from a genetic counselor, or that expertise that I have, because of my training, you aren't able to have them go through donor cycles, like if you found a genetic mutation, and they now know that there's something wrong, they're gonna do egg donor or sperm donor, and you're gonna be able to engage them. So when I wrote the business plan, those are the avenues that we were able to do and you wouldn't believe it. Like in the first three months of our genetic counselor working, we were audited, like any other practice with audit their new process, and we were we were cutting even because like I was able to see double the number of patients I like I was seeing my own infertility patients, and also seeing a patient with the genetic counselor at the same time. So her time and my time was build right and then I was able to feel a level higher than what I would with her support. So if you have a comprehensive visit, they are able to spend half an hour with me and then half an hour with my genetic counselor. We are able to provide the best possible care for them. We We are able to solve some of these complicated situation order the required amount of testing on that same day, and then I was able to build a level five visit. And because we were able to get them to write tests, we were able to engage them to do IVF with PGT M, PGT SR, which is like many, many cycles would come out of that one, one situation for that couple, they might do multiple cycles to find the right embryo, and then they will come back for their second and third children, because their embryos are stored with us. So if you are able to do the math there, you know, you did multiple IVF cycles out of that one console that you could do because of your expertise or your partnership with that, that genetic counselor. So and, you know, Amber, gamma had previously told you the salary that a genetic counselor would have, it's usually I heard her podcasts with you, and she mentioned somewhere around 100, 250,000 Is what she mentioned, based on their professional society survey, 100 or 150,000, you are able to do it, get that revenue back in a few IVF cycles. Right? So it's like, yeah, so it's the understanding of the best care for the patient, in a model that embraces that new technology. So you're freeing up your staff, you're freeing up the doctor to do other things they are able to do IVF practice while that person is totally every day doing complicated genetics for you.

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Griffin Jones  27:19

Maybe we should talk about that time that was freeing up for you because I'm understanding the picture of the revenue that is generated downstream from the genetic counseling that you're painting. I, if I were a hiring doc might look at you and say, well, I've got you, what do I need to hire a genetic counselor for you just did this double fellowship, you have this genomics experience and credentialing, so why do I need to hire a genetic counselor when I have a doc that also has this training?


Dr. Mili Thakur  27:49

Sure. So one of the key things pioneers in the field right now are talking about this, you should use or utilizes the right word, everybody at the top of their license. So for me as an REI, the top of my license is surgery. Right? So if I'm doing a hysteroscopy, if I'm doing an egg retrieval, if I'm doing an embryo transfer, nobody else can do it in my practice. The nurse can't do it, the genetic counselor can't do it. So that's my top of the practice. What the genetic counselor does is she works, she or he, you know, any they work on the top of their license, and their top of the license is to be able to take that information, break it down into an actionable plan, get the testing ordered, and then be able to give the test results. And then you're able to utilize the doctor's information of like, oh, yes, you need IVF. And you're able to use their expertise to take that patient through IVF. So the way we have it in our practice, and, you know, I'm about to launch a new venture where I would be working as a liaison like I want to uncover the case for the doctor to then take it through for IVF.


Griffin Jones  29:05

I want to ask you about how you would liaise with them and what you plan to do for that venture. I'm interested and it's making sense the type of license argument for your genetic counselor, there's four or five Doc's in your group four or five REIs? 


Dr. Mili Thakur  29:21

Yeah, so there's four, 


Griffin Jones  29:23

Do all of the docs utilize the genetic counselor or or just you?


Dr. Mili Thakur  29:29

The way we have it set up in our practice, or the way I set it up for our practice, is that the genetic counselor is available for any of the patients that are going through so we have tried to specialize in genetics for the whole practice. Nobody else except for we and the genetic counselor and we have an genetics assistant are the ones that are holding all the workflows of the genetics so the dogs don't have to worry about it. The nurses don't have to worry about it. They don't even give the test results about They don't even get a phone call, we have kind of streamlined it to just be our area. So it takes away from the headache that the other doctors would have to face. So if the complicated case comes through, we prep the whole thing for them. And then the IVF still goes under, through them, for whatever needs to be done, 


Griffin Jones  30:23

How does the way that the other REIs interface with the genetic counselor differ, if at all, given they don't have the double training that you do?


Dr. Mili Thakur  30:34

So they could take care of the case, as anybody else would, like, all of my colleagues in REI, without the extra genetic traces are, are able to take care of most cases, you know, unless there is new testing that's required, but they're gonna be able to achieve that at the cost of time, they're gonna have to spend four or five hours per case, at least in our practice five to 10 hours minimum to get that case to get through, it's a high stakes liability case, when you're doing a PGT M case, right? Because you they are not necessarily infertile, they're just coming to you to be able to have a healthy child. So it's a different kind of scenario. So that doctor will be able to still do it, they will be able to look up the mutation, go through all the history and everything, but then they're going to be utilizing the time, by having our model of like somebody specialized in genetic taking care of all of your genetic needs, you're able to free up that time, you know, I prep the case, I see all my cases with the genetic counselor, I understand it, it's easier for me, because I do that every day, I'm well versed in the technology and keeping up with the science of it. And the genetic counselor is part of a group of elite group of genetic counselors in the country. So she understands what is going on, we keeping up with the science of it, were able to prep the case. And then the doc can just meet with the patient and say, hey, go ahead and meet with our team, and they're gonna take excellent care of you, we prep everything. And then they go see the doctor again and say, you know, we have this is what we found. And this is what we are going to do, then you take them like a regular genetics case. And when it comes time to give results. Again, after the IVF is done, and the embryos been tested, which embryo to transfer, you know, it's a very critical decision making. And again, it comes back to us we meet with the patient, we give them the test results, and then you're back to transferring an embryo vision areas workflow anyway involved. So the doctors can rely with a lot of firsts on our team, and then get back to what they were doing. In the meantime, they're not spending extra time to be able to understand the new mutation or understand what needs to be done. Sometimes you have to call these genetic testing companies, you know, many of these countries have done more than 5, 6000 cases, right? So for 800, 900 disorder, but I feel like 901 disorder comes you sometimes have to call them and say, you know, is this something we can do for this family. So you're spending the back end time, it's just being taken away by this specialized group. So what I'm coming to, again, is that there is this need inside of our field to recognize that genetic testing is here to stay, it's going to become more and more complicated. The technologies are evolving day by day, the doctors in REI can lean on a group that is going to be just doing genetics all day. And they are keeping up with all the things and reading the different tests and the technologies that are coming through and then do what they do best, which is patient care. So they're not like worried about okay, they did get documented in the chart, that a certain embryo should not be transferred or should be transferred, right. It's like a busy practice for most of the areas that I know about, you know, they shouldn't be burdened with something that they're not doing every day. You know, these cases are special cases that require a certain amount of focus that has to happen. 


Griffin Jones  34:16

So I'm seeing the focus that's necessary and the support that's necessary from the genetics counselor, and even the revenue upsides that can come from it. I want to push a little because as we talk about scaling, I imagine that this is the people who do the scaling what they think about in that okay, so I buy your case for a genetic counselor, I see the revenue upside I see how much they help the doc why in house though, why isn't this something that we can outsource that we can do via telemedicine that if we've got a network we can you know, maybe you will maybe we got 100 doc's in our network across the country and we have four or five genetic counselors. Why is this something that has to be in house in your view?


Dr. Mili Thakur  35:00

For me, it needs to be in house because you know the type of volume that I do. So the volume justifies what you're able to build for and keep up with it. So if it is network, or if it is a high volume, practice for sure, they should have some sort of partnership with either an in house genetic counselor or a company that just takes this whole genetics and does it for their practices or you know, the clinics that they are. Or if you're a small practice, you're not going to be able to afford a genetic counselor at all. At that point, you could have a hybrid model. So hybrid model means that you know, you could do some of your regular day to day genetic results giving through the company. So all of these reference labs will have genetic counselors, and they can give easy test results. They're not based inside of the practice. So they're not able to tell the patient what to do or what not to do, they don't basically take away the work from a nurse or the doctor, but they are just a resource. So that can be some of the results that can be given. And then you could have a group of practices in sharing a genetic counseling service or telemedicine genetic counseling service, there's a few of them right now. And a lot of people are leaning on them after what happened in the IVF field with some of these big tech companies, genetic testing companies, you know, entirely dissolving their fertility units, there were no genetic counselors available for a short period of time. So telemedicine companies to con that extra work, and then if you're a big volume, practice, and you're able to justify a genetic counselor, you should have some partnership with either an in house genetic counselor or through a company that takes on that work for you and not worry about it. Because the revenue will be generated in no time, you know, I have no doubt about it. But if you're a small practice, you're doing like less than 100 cycles, you're gonna see maybe one or two generic cases in in a month that it doesn't make sense to have a genetic counselor. Although another thing that I wanted to kind of point out as if somebody has that genomics business aspect of it, we are only scratching the surface of what is the potential out there. So there is a lot of families that want answers, they just don't know that they want answers. So if somebody wants to build a bigger practice, they are smaller practice, but they want to do more cases, by building your genetics brand, you can like be stronger. So there's all sorts of models. And I think at this point for what I see in the field, a hybrid model is good. That means, you know, depending on what you can and cannot do you lean on a certain way.


Griffin Jones  37:48

So for you hybrid wouldn't work because your volume is big enough, can you give us a general rule of thumb, like a ballpark rule of thumb of what number of genetic cases make sense, where the genetic counselor should be full time in house,


Dr. Mili Thakur  38:03

I think it depends on the total number of patients coming through in a year or a month for a patient for practice. So if a doc is saying about, like, I would say if a doc is seeing about like 10 to 12, some of 15 new cases in a week, you know, there's going to be at least two or three of them that are genetics, or their hidden genetics, like they're not obviously I but like recurrent pregnancy loss. So, you know, if you're, if you're seeing five or six recurrent pregnancy loss patients in a, in a week, you know, in about two weeks, you're gonna have a PGT SR case, because you're going to find a balanced translocation in one or the other patient. So I think it would be dependent on the total volume that you're able to bring in to the practice. 


Griffin Jones  38:56

But that's not crazy, high volume, I suspect that the probably the median of people listening is probably doing that doing that about 10 to 12 new patients a week. And so you're saying of those 10 to 12 new patients, you're likely going to have two or three cases that,


Dr. Mili Thakur  39:11

If you're looking so the caveat to that is are you looking, you're gonna only find those cases, if you're looking very well. So like, in our practice, we have a protocol. And you know, for my new venture, I have a protocol that if you have a couple that has male infertility, and the count is lower than 5 million, you have to look for the karyotype of the male to find the translocation. And then if you have to do the Y chromosome testing, so if you did enough tests, you know, about 10% of them are going to be abnormal, and then you're going to find that one extra case that you solved. So you have to be looking, there are other ways of doing it. You know, the count is low, let's just do IVF. Let's just, you know, make embryos and that's why you have sometimes failed IVF cycles after failed IVF cycles, because the protocols that have been given by our professional societies are not being able to be followed. Because you know, it's like a cookie cutter type of model that's going through, like everybody comes in, let's do some IUI. And let's do IVF. And then if you don't get pregnant, that's bad luck for you. But there are these cases that are hidden, you have to go and follow the guidelines to be able to find those answers. So we look for them, and we find them. And then because of our relationships with geneticists in the area, just because of my interest and my expertise, you know, we get direct reference. So I, I don't find PGT M cases based on carrier screening alone or male factor testing alone, I get direct reference. So people will come to me and say, we just had an affected baby who was in the NICU, and this couple is thinking about another baby in two, three years, can you see them? So we are getting these other reference cases, which right now, most practices, and I've talked to all the big networks, mostly, you know, about what they're doing, there is no process right now of capturing those cases, which, you know, by having that genetics, specialization, you're able to get those relationships. And then another thing that we have kind of leverage quite a bit is oncofertility. If you have relationships with oncologists in the area, you're going to get to serve patients who have a genetic mutation for cancer. And then you're able to do IVF procedures for them, whether it be like egg freezing or it be sperm freezing, or it be you know, embryo freezing, and an embryo freezing with genetic testing for those. So you have to genetics is an all encompassing thing like it, it percolates different areas are male factor is one pregnancy losses. And other one, cancer is another one, we capture them from all different areas. And you know, we are able to bring it to the forefront, sometimes the patients don't even know they have the issue. And now the whole plan is changed. So sometimes they will come for like, okay, male factor infertility, we wanted to semi, but then you find something and you show them and say, this is a condition that, you know, could affect the children. And you know, we can test for it. And then you change the plan to an IVF plan.


Griffin Jones  42:31

And part of the all encompassing of what you're talking about is being used in ways that are applied beyond infertility cases, but simply for anyone that wants to avoid genetic disorder using genomic says part and using ART as a means of how they have their kids. I want to talk about that broader market implication, I have one last question on the carrier screening that I can think of because you've you've made the case for a certain volume, where it makes sense to have genetics counselor, where you've made the case for the the revenue streams that come downstream from generating that you generate with genetic counseling, you talked about the patient retention benefits, and you talked about the donor cycles is all of this enough at scale, for you to choose a carriers screen name company that might not be able to do a certain deal if another carrier screening company can cut a really low deal. So I'm thinking of the MSOs as they start to consolidate fertility clinics, as they start to broker these deals to ostensibly drive down costs. If they go with one that is they can do a really, really low deal. And perhaps one that meets your vetting criteria can't Is there enough in those three areas, patient retention, downstream opportunities and donor cycles, that makes that is enough to offset big deals being done at the enterprise level?


Dr. Mili Thakur  44:13

So the point of the whole discussion at this point, Griffin is that the experts in that field should be part of the decision making process. The reason being that if if a non clinical person takes the decision, and you know, makes it a low cost test is available to everybody and everybody binded is bound to use that test. Then at some point it's going to be affecting in an indirect way. So what I mean to say by that is if you have a non clinical person somehow cut a deal without understanding the test and its implications downstream. There could be an error that can happen or an oversight that can happen and then that one or two cases will suffice for, like a huge liability. And that's why you know, all all of these clinical decision making, especially in complicated areas, so some of the complicated areas that I see in, in IVF, or infertility care as such, one of them is genetics. It's like, really, really multifaceted, complicated. There should always be a person with specialized genetics training, be it like an IVF doc with genetics training, or a genetic counselor who's trained in that field be part of that decision making, they should be sitting on the table and saying why or why not? We can do that.


Griffin Jones  45:35

Let's zoom in on that for a second, because I think that might actually be more at the crux, because it could be a clinical person that makes that decision. It could be the chief medical officer, who is an REI, I've had multiple REIs, to me say they don't care who the their carrier screening provider is that it's all the same to them. And so does there need to be, does there need to be something in the governance of a large network where genetics is represented? Or is it simply the case that the docs and the genetic counselors with that experience need to make that case to their, their chief medical officer? Or do you think there needs to be something baked in to the governance of an organization where there's more consideration of genomics?


Dr. Mili Thakur  46:20

So the way I see it is like in any organization, the head of the organization or the decision making, they have advisors? So So a good example is the President of the United States signs off on a lot of things or, but they have like NIH chief, as being their advisor who sits with them and says, Why or why not they should be doing something, or they have a surgeon general. So if a Chief Medical Officer or CEO is going to be taking those decisions, they should have a clinical genetics train person when they are saying yes or no to a certain company and say why or why not? Because if you're going to have, say, $5 difference between which is like what is happening in the field, right now, genetics is becoming less and less expensive right now. And it's going to be available. There is a $5 difference, but there is a huge difference in the clinical strength of the test, you know, would you go with, the better test? Or would you go with that $5 deal? Because I think I in one of your previous episodes, do you know, one of the doctors who talked about how to cut costs in the in IVF talked about that they would never negotiate the price or go with a crappy incubator, because the embryos are going in there, versus a speculum is easier to make the decision making. So like, if you're going to be doing something. Right, and taking a decision about it, that's binding to multiple clinics, you should always have an advisor. So you know, I've been an adviser to a lot of those, those experts that are taking the decision in multiple different categories. And that's the way to go. Like you could have somebody who can give you advice and tell you what's happening in the field and why and why not that things should be happening. Because when a non clinical person or a clinical person who's not an expert in that area takes the decision. They don't know, you know, what they're saying yes or no to and the drug reps sometimes don't know, I've had multiple instances where myself and our genetic counselor is the one who's telling them, can you tell me this? And then they'll say, Oh, let me find out from the genetic counselor in our lab, she probably will, they would probably know better, as to what is happening. So the, and the salesperson is doing their best. They're not clinical people. You know, they're not doing genetics every day, they are selling the genetic tests, but their education is in marketing or in sales. So you know, the person. Any REI physician out there, who's now offering a test to the patient is going under their license, all the testing all the results giving all the downstream effect of it is under the REI who did that, that care. So sometimes we don't have the bandwidth to do all sorts of things. So you have to quickly decide how how you are going to navigate that whole system. Like if you have the capacity, there are some areas who might feel extremely comfortable, they have done 1000s of cases of this complexity, and they feel great, wonderful. But then if somebody has been practicing in the field for a number of years, and they are not kept abreast with the technology right now, they're better served with like having somebody else be their partner for just that little piece of it, and then you go back to doing what you're doing. But you consulting advisors, or I think the way to go, I don't take any of the network's would want to take decisions on a clinical thing. without consulting the right expert for anything like if I wouldn't set up an IVF lab without an embryology lab director, like I don't know what happens inside of that place, right? I'm gonna have an embryology person, a PhD in embryology, set by me and tell me and then we can do it together. Right? If I was opening the door for a new test to be brought into the system, I would want to know, you know, what does the test do? Why is the cost higher than the other company next door? Like what are you doing extra that other person is not doing? And they can like tell you they very well, the salespeople would exactly be able to pinpoint the difference. And then you say is the difference like something that's just a frill? Like, is it just something that's additional? Or is it like really something that's like a clinical change, it affects us, it has a huge patient advantage of going with a certain company. 


Griffin Jones  50:51

Well, let's talk about what it's going to be like as it becomes more of the marketplace. So Dr. Stable has been on the show, and he talks about genomics and ART as infertility just being a fraction of what that could be for the general population. I've had other people on like Jamie Metzl, the author of Hacking Darwin, who I don't want to paraphrase him too much, but he posited something like, within a few decades time, we would expect almost everybody to be born from ART and using genomics as part of that. Where do you see the marketplace going?


Dr. Mili Thakur  51:31

So I think in the next 5 to 10 years, you know, there is going to be emergence of a lot of new things. So what we're going to see in my mind, is whatever has been available is still going to be continued to be available. But there's going to be this emergence of new technology with all the big data analysis that's now going to happen with artificial intelligence, there's going to be new things that we are going to be suddenly be able to offer to patients. And that's why you need to develop the workforce. So if there is any listeners out there who are looking for the next big opportunity of like, where to invest, you know, genetics is one of those big areas. And that's because there's going to be this influx of information that's about to hit us, that's going to be all these new tests and all these new data analysis that is available, are we ready for it? Is there a company out there, you know, that's able to just handle all that needs that these doctors are going to suddenly have to face? You know, that's the, for the next 5 to 10 years, we're going to be in transition, like it's not going to be an overnight change. And artificial intelligence in all different forms needs to learn, and it's going to learn from humans. The second thing is that on the other side, have any of those tests like or any of that artificial intelligence, data analysis is a human, you're still going to give it to patients, and patients have physical needs, they have their emotional needs, they have their family needs. And you know, no, no deep learning language model is able to tell a patient or comfort a patient who's crying, you know, sometimes these genetic test results bring an overwhelming amount of information. And, you know, so there is going to be the transition. So we will have our traditional models still be there, and then this new emerging technologies are going to overlap. And then at some point, you know, hopefully, we are able to get to a point where everybody is able to benefit, like, I'm a huge, huge proponent of proactive genetics, like in my mind, at this day and age, a young person should never be in the blind, they may or may not choose to do the testing, or any of the IVF process to take care of it. But they should, they should not be a single young person in this day and age in the US who doesn't know that they have a high risk cancer gene in their family that either they are a carrier or they're not or that they're a carrier of a certain preconception genetic carrier condition that's available by a saliva test done in about two minutes, and doesn't cost too much. And they still don't know their carrier status, like we have to change that we have to bring genetics to the mainstream in an easy way. So everybody knows I'm a carrier of cystic fibrosis, and you know, I'm going to test the partner if they're going to ever be in a relationship before they have a child so no child is then affected.


Griffin Jones  54:47

You're making a really strong case that this is one of the biggest investment opportunities in this space, partly because, why does anyone have to be born with a chronic disease that could have been preventable and that pool of people is even larger than the pool of people that we're serving now. But if it is one of the biggest areas and opportunities for investment, Mili, why doesn't it look like it is right now?


Dr. Mili Thakur  55:14

So the reason why it does not look like right now is because the two fields are being seen separately. So the advantage that I have is that I see both the fields and I have this view, vantage point that's different. So IVF, doctors specialize in doing IVF and taking care of couples who are trying to conceive by non IVF processes, right, they are busy with it, that's what they do. The doctors in genetics are busy taking care of people who are sick. So any genetics department is mostly situated in an academic center, and they are taking care of the reference that they get to find answers after the disease has happened. You know, from my vantage point, though, there is this huge gap in between those two specialities that can be filled. So if there is somebody out there who's able to uncover the risk for individuals who are not sick yet, you know, we are able to prevent the disease from happening, and also be a partner to the IVF practices for something that they're not even getting a referral off. So the reason why it's not been seen as an opportunity is because it's an untapped market. It's not been tapped, because the two specialities are not being able to see that. But from my vantage point, and with the expertise that, you know, we are able to have, you know, I'm able to see it, like it's right there. And it's been pointed out by a number of prominent speakers, you know, preventing adult onset cancer in our child, it would be huge, like, they would not have to go through all these screening tests and risk reducing surgeries that, you know, adults now are going through, but you don't test for these conditions in a baby or a child you test for these conditions and a transfer a disease free embryo. The same thing for neurological conditions, you know, there is conditions that that can be prevented the same thing with newborn condition. So newborn diseases, you know, are inherited metabolic diseases, and it's preventable. It's like completely preventable, if we are able to merge those two fields, and that merger will happen. But the opportunity lies now because it's untapped.


Griffin Jones  57:45

These genetics companies that have closed their fertility divisions, are they going to be able to get back into this space, this merger of the two worlds as you describe it? Or are they going to regret closing their fertility divisions?


Dr. Mili Thakur  57:59

So I think what is driving their closure is not a disinterest in the field. I think it's the challenges that the financial world is facing right now. And, you know, if they're part of your audience, you know, I would want them to look at that, again. So at this point, when the technologies are emerging, you know, you have a better view of investing in that thing. So right now, you know, a good example would be the artificial intelligence field, it's not there yet. But all the venture capitalists are looking for the next best thing that's going to be there on the horizon. And in our field, you know, one of the there are multiple fields, multiple things that are important. One of those things is reproductive genetics. So right now, whoever focuses on reproductive genetics and builds a strong infrastructure around it is going to have a definite advantage, not at the current time, it would start to show in the next 235 years, so technology in genetics is not going anywhere else. The biggest advantage they would face is the same advantage that the practices that invested in genetic testing for cancers have so good analogy for some of the people who are thinking about jumping into this field or, you know, thinking about it, is that in cancer, feel you you are able to serve the patient by doing chemotherapy. And right now, there is a whole science and a field that has developed inside of the cancer field, oncology field, that banks on molecular testing for the right mutation and the cancer and then giving the right chemotherapy. So any pharma company who was going to be developing these new tests needs a genetic mutation, and anybody who's going to give that chemotherapy so that hospitals benefit by giving the chemotherapy to that patient and the insurers the insurance companies better become stronger. So everybody in that whole system that so basically what I'm trying to say is we need to develop an ecosystem that combines the different genetics inside of the reproductive field right now they are scattered, they are in different locations. And we need to create that ecosystem with the understanding and the nurturing under a specialist.


Griffin Jones  1:00:26

Where does the new venture that you're working on fit into that ecosystem?


Dr. Mili Thakur  1:00:30

So I want to create that ecosystem. So the new venture that I'm venturing in is is genome ally. So we want to be partners for anybody's genetic needs. The first phase of that venture is to be able to help patients uncover their risk. So proactive genetics, to be able to make them aware, have them do the testing, get the test results, and then you know, if the test results are negative, they go back to their normal trying or, you know, family building as they please. But if we uncover a risk and we find something, then they are able to go through the process of IVF to prevent the disease, that they are a carrier, often, it also helps them proactively take decisions to be not getting the disease that they carry. So if it has an adult onset condition, if we take care of somebody who's like in their 20s, or 30s, they're not going to be suffering from lung cancer, because you already picked the condition and you're able to do it, it's going to also benefit some of the other specialities in our field. So if there is an employer based benefits company, if they're able to provide that to their employees, you know, it's a huge advantage, you're going to have a person not drop out of the workforce, as a young person with an adult onset condition are you going to have a family not get affected by a newborn, who suddenly so sick, and then they can't come to work? You know, these conditions are very rare in individuality, but then when combined together, it's a very big group. So I was looking at the data the other day, you know, there are about 3000 babies born with a certain number of a certain condition, and then 3000, more and 3000, more and 3000 more of certain other things. So if employer benefit company is able to provide the service to the employees, we are going to find some some families that are going to not then use up a whole lot of insurance and have sick children or have a disease to themselves. And it's a win win situation, it's the biggest win for the patient, that now doesn't have a preventable condition. It's a big win for the child that is born that is healthy, and doesn't have to worry about it in the future generations. And then it's a huge win for the employer because they get the goodwill of the company plus also for the benefits company, because they are they were the one for you know, your listeners and Walt progeny and carrot and Maven and all of these employee benefits company, it's such a huge win for them


Griffin Jones  1:03:15

Will Genome Ally be a carrier screening company, as part of it, or is it partly genetic counseling platform that interfaces with any kind of carrier screening company? How does that work?


Dr. Mili Thakur  1:03:31

Yeah, so I want to partner with industry partners. So what I would like to do is I would like to be the one providing the consultation and ordering the test, giving the test results and then bridging them to the required specialist. But then I would work with the industry partners and select them carefully to see you know, which one we are going to be using. And it changes over time. Sometimes these companies as you know, are evolving, you know, they come out of a certain test and don't do that test anymore. So, you know, you should be able to do what you do best and not reinvent the wheel. So if there is a donor company, right, that has like egg donor sperm donors, they're only needed to like match the intended parents with the right donor, and then we would, we would be able to handle that little piece of it while they do their job of matching and doing the cycle and everything. So what I'm suggesting with this company, and you know, that's my vision of the company is to be able to develop that ecosystem of having different partners and being providing the service that is required for reproductive genomics in a wholesome way. The first phase of it is going to be direct care. So be able to see patients whether they are coming to us, you know, by direct marketing or whether they are coming through employer benefits, you know, with that would be a huge advantage for the patients.


Griffin Jones  1:05:01

How far along are you with this venture? Are you just proving concept right now? Are you raising money? Are you selling any early stage customers? 


Dr. Mili Thakur  1:05:09

Yeah, so we are about to offer the services to patients, you know, the website should be ready in the next few weeks. So by the time I think your episode will air we there should be a website that's available, you know, I have all the other required things. And because, you know, in this day and age, you have to be ready to scale up pretty quickly, the scalability, I might consider investors at that point, but right now, you know, I just want to take some patients through and to and to be able to, you know, be in the know, of like, how the whole system works.


Griffin Jones  1:05:49

Yeah, I think that it's also really good to have something that you know, is going to scale, when you get the investors to help scale it. I think there's been a lot of people in the era of free money that have had ridiculous valuations, just to prove a concept that was never proven, we might be going back to the era of you work hard to build something to prove the concept. And then and then you can get people to scale it. And so you've got something here in that school, that it's that right now. It's you, you know, it's your your venture, and there's no outside money in it. We've covered a lot of ground today, Mili, and we got deeper into carrier screening than I thought we were going to, but I'm glad we did. Because you've you've convinced me to the extent that I can be convinced I'm not a clinician, but you've convinced me that it isn't the commodity that maybe I'd gotten the impression that it was but of all of the topics that we covered today, how would you like to conclude?


Dr. Mili Thakur  1:06:48

So I would like to say that, you know, in your audience, there are different types of stakeholders, and they all have like a different vantage point of the field for reproductive genomics. At this point, we are at a point where there would be a lot of emerging technologies, we have to be ready for taking care of the patients as we are bombarded by these technologies. And we should be ready to take care of the physicians and the clinical staff in an IVF practice, to be able to support them and giving the best patient care is going to cause them to have better patient engagement and retention, and then it will help them generate revenue for the practice.


Griffin Jones  1:07:36

Dr. Millie Thakur, thank you so much for coming on the Inside Reproductive Health podcast. I look forward to having you back on in the future.


Dr. Mili Thakur  1:07:44

Thank you so much for having me, Griffin.


Sponsor  1:07:46

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Contact bundle at bundle. That's bundlfertility.com/contact-bundl. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest appearance is not an endorsement of the advertiser. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

190 Letter of Intent: How to build the foundation for selling and buying a fertility clinic. Richard Groberg and Jay Stucki

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Gain expert insights and invaluable advice on navigating the sale of your fertility practice with special emphasis on that crucial document - the Letter of Intent. Richard Groberg, a seasoned financial expert and Jay Stucki, an experienced corporate attorney, share insights from the sell side perspective and zoom in on the details that matter most.

  • Discover the major points addressed in the Letter of Intent that serves as the foundation for buying or selling a company.

  • Delve into comprehensive coverage of key elements in the LOI including:

    • Insurance

    • Non-competes

    • Governance

    • Equity

    • Evaluation multiples (based on adjusted EBITDA)

    • Profitability conversion

  • Acquire valuable knowledge into the process and timeline of finalizing the LOI and next steps to completing the transaction.


Jay Stucki:
Stucki Legal, PLLC
LinkedIn

Richard Groberg:
LinkedIn

Transcript

Jay Stucki  00:00

I think one to start with, they don't understand the 30,000 foot view of how important the loi, or the letter of intent can be. That is the roadmap. And unless you know where you're going, and you've been there, is it hard for generic LOI?


Sponsor  00:18

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Email Courtney at cbarrett@bundlefertility.com. That's cbarrett@bundlfertility.com. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health. Nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.

Griffin Jones  00:59

Are you serious? Are you serious about buying my fertility practice? We'll find out from the letter of intent. That's the topic that I zoom in with my experts today. Richard Groberg and J. Stucki, Richard, you know, because he's a financial expert who's been on the show multiple times, and he's given plenty of advice on what you need to consider when selling your fertility company. Jay Stucki has also represented fertility companies on both the buy side and the sell side, or at least he's represented companies on both side perhaps fertility was just sell so I didn't get into that specific but today we talk from the sell side perspective. She's a corporate attorney whose careers focused on estate planning, asset protection, real estate transactions acquisitions, in medical and in software for decades. And today with Richard and Jay, I decided to get very specific on the letter of intent. The loi is what they call the roadmap or the foundation for buying or selling and company. They talk about the major points of an LOI, what happens to your malpractice insurance, the noncompetes post closing governance, rollover equity, equity and apparent company working capital like how much cash and accounts receivable you need to leave in the business for how long controlling documents like medical direction assignment of membership interest, joint operating agreements, irrevocable proxies, employment agreements MSA agreements, your valuation multiple based on adjusted EBITDA converting your profitability if it's based on cash, accounting, or cruel accounting, what needs to be talked about in the three to six meetings that happened before signing an LOI? What happens in the very early stages signing your NDA what happens between them and how the letter of intent is finalized? Any one of those subtopics could be its own topic on the show. I'm sure I'll have them back on to discuss because of so many of you are at this stage and you want to get this right. Enjoy this conversation with Richard Groberg and Jay Stucki about constructing your letter of intent. Oh, and I probably have to give you a disclaimer. This is not legal advice. I'm not an attorney, adjacent attorney, but it's not legal advice, simply insights for your informational use only. Mr. Groberg. Richard, Welcome back to Inside Reproductive Health yet again. Mr. Stucki. Jay, welcome to Inside Reproductive Health.



Jay Stucki  00:59

Thank you, glad to be participating today.



Griffin Jones  00:59

Richard, the audience is a little bit familiar with you at this point. You have been on the show a couple of times. And you're also quoted from our journalists when they are doing articles about some of the business dealings happening in the field. Jay, you are a corporate attorney? Are you mostly Is it mostly sell side that you represent? Are you sell side and buy side equally?


Jay Stucki  03:40

No, I wouldn't say equally, probably mostly sell side. But I've been on both sides of the table. So I've got a depth of knowledge level from each perspective. And I've also worked for practice management companies. So I get the physician side, I've had to represent many physicians and getting them out of bad contracts. So I think I kind of bring up a bit of expertise to the layers that most attorneys won't see.



Griffin Jones  04:14

One sub topic that was popular that we covered with Richard was talking about mistakes that Fertility Centers often make when they're selling with regard to accounting, things that are categorized as business expenses that shouldn't be and that impacts their EBITDA. What are some of the common mistakes that you're seeing from a legal perspective when people are going to sell their fertility company?



Jay Stucki  04:38

I think one to start with, they don't understand the 30,000 foot view of how important the LOI or the letter of intent can be. That is the roadmap and unless you know where you're going and you've been there is a bit hard for generic LOI. I you know, I like in the the legal side of things, you know, if you, if you're a couple and you want to get pregnant, you're not going to rely solely on your GP or internal medicine, you're going to want to go to a reproductive endocrinologist, you need that specialty. And it's the same thing in law, you need someone who knows both sides of the table to really hone in, I think Richard could probably give you a couple examples of allies that were vague from the start, because they didn't understand the full process of where this needed to go at the end of the day, how to protect the physicians, and yet make it a deal that works for both the acquiring entity and the seller.



Griffin Jones  05:44

What are a couple of those examples? Richard, do you have any LOIs being too vague from the start?


Richard Groberg  05:52

Yes, I've seen a couple recently that were negotiated by people other than me, when a couple of examples, most of these transactions talk about the fact that the valuation will be a multiple of what's called an adjusted EBITDA, which adds back and subtracts for certain adjustments. But if the language is unclear that that includes converting the sellers profitability from a cash basis accounting to an accrual basis accounting, they can wake up a month or two months down the road. And their adjusted EBITDA is significantly different than what they thought it was. And it can cause problems. The other issue I've seen recently, is where the seller also owns real estate that's used by the practice. And if it's not clarified, that the post closing lease rate will be based on some combination of the current rate and an independent appraisal, then, and that's that final number could affect the EBITDA and the valuation and the purchase price. It can cause problems later on down the road. Jay will talk about other issues in terms of duration of non competes, and the various different non competes. And what happens to rollover equity in the practice or in the corporate group acquiring if a doctor leaves early or is fired for cause. But those kinds of things, especially when Jay and I are working together representing a seller, we work very hard to make sure that the major issues have very clearly negotiated will define so that we don't get down the road and then have problems a month, two months later, when everyone spent a lot of money on accountants and lawyers and other advisers.



Jay Stucki  07:45

And let me just add to that, that, you know, you're you're trying to look at the entire structure, I can't tell you how many LOIs, I've been handed, and it was going to be a stock purchase agreement or an asset purchase agreement. And because of the structure because of rollover and contribution, tax considerations, it ends up getting flipped, and we end up with a completely different structure. So it it's more than just, you know, understanding noncompete or the quality of earnings. It's the LOI really has to look deeper into how the sellers were organized formed tax consequences, how long they've had ownership, short term, capital gains versus long term capital gains, estate planning issues, especially if there's a rollover component.


Griffin Jones  08:38

Why is this those and maybe it'll just enlighten my own ignorance. But to me, that the LOI was simply the the letter that says, you know, we're going to do our due diligence, we're going to explore a deal, but it sounds like more of the terms of the deal need to be established in the loi, where I would have thought, well, you know, if the if the valuation multiple needs to be adjusted in a better based on adjusted EBITDA and that might change, that that would just happen in the deal doesn't necessarily happen. And in the LOI, why does this stuff need to happen in the LOI?



Jay Stucki  09:16

Well, the LOI can't be as detailed as the definitive documents, obviously. And as the saying goes, the devils in the details. And so when you get into negotiations, and you're trying to explain the pros and cons of certain language or certain concepts, it seems to always harken back to well, that's not what we were told when we were being courted. And so it's very helpful that even though the LOI is probably only going to be a few pages long to be able to go back and use that as a tool for refreshing the memory of what was being said during the courting and, and I've watched effect I've used Richard to be able to go back and say, Richard, you were involved in this LOI and negotiating upfront, what was the understanding? And then you get all the parties together. And you walk through, yes, that's what was said, oh, shoot, okay. And just because the buyer said something, it doesn't mean it translated over to the attorneys. So you kind of have to get the attorneys back on track to be in line with what was negotiated under the LOI.



Richard Groberg  10:32

If and if I can amplify that, Griffin. At least in the transactions, I've worked in the sellers, this is a one time thing, they've built their practice, they've operated for a number of years, for various reasons, they're ready to sell it a partner with a PD back group, they vet two or three, or perhaps more potential sellers, they've made a decision, it's like, This is who I'm gonna marry. Because it's not like selling a piece of real estate where you sell and walk away. And when the LOI is signed, both sides start spending a lot of money. It's a time consuming, painful process. And you want to, again, there's a balancing act, if you negotiate every possible thing, you have a 200 page document in the loi, which you can't do, but you want to lock down enough of the major points, some of which are very subtle. I'll give you another example. If one of the buyers has their own malpractice carrier, and everybody has to switch, and they're requiring the seller to have to make the switch and by a tail policy. Well, that affects the economics of the deal. And if one of the sellers is ready for retirement, that could affect the structure. So as much of that, that says very significant could be at least buttoned down enough that when we get down the road, the lawyers could say, hey, Richard, while you were there, what Jay said, what was it that the parties discussed and agreed to? It helps lock in the major points.



Griffin Jones  12:04

Let's talk about those major points. You mentioned malpractice and the potential for needing tail policy. You talked about the valuation multiple and adjusted EBITDA or the potential for converting sellers profitability based on cash basis accounting or accrual based accounting. What are the major points that need to go in to a letter of intent?



Richard Groberg  12:28

I'll give a quick answer. And then Jay will come in too, the noncompetes are very important. post closing governance is important. Not all the groups are the same, and not all the sellers are the same. Some sellers don't need a lot of help from the corporate group, and how much interference there's going to be becomes important issue some need more help. So discussion about governance, to the extent they're getting rollover equity in the practice, what fees the corporate group charges or doesn't charge and how it affects profit participations. To the extent the sellers are getting equity in the parent, how that's viewed and what happens and get what happens if somebody leaves early. How whether working cow working capital is calculated, most of the buyers require the seller to keep enough cash or accounts receivable in the business to cover bills for a period of time. Others allow the seller to keep the accounts receivable wanna J's favorite issues to battle is? Okay, what are the reps and warranties and indemnifications? And what is the seller responsible for post closing but may have occurred? Pre closing? So, Jay, have I missed any major ones?



Jay Stucki  13:47

No, I've just say that there's so many different subsets. So for example, if you're talking about could controlling documents, you're going to have a whole different set of considerations under an employment agreement that you're going to have if there's rollover contribution, and now you become an equity holder in the parent company, versus when restrictions and covenants that you're going to have in the asset purchase or stock purchase agreement. And all of those will carry a whole different slew of requirements. And so it's, you will see some of that addressed as to what the expectations are between the parties in the LOI, but it's not just oh, hey, a traditional non compete because having equity in the parent. And if the parent would say is a limited liability company, you're talking about now coming in as an equity owner, do you have a say, what's your vote? Are you just a financial interest? I'm sure there's going to be power of attorney considerations. So you're going to have contribution tagalong, drag along, right I mean, there's all sorts of things that now come into play is that owner that in the parent, and of course, the parent doesn't want a minority owner controlling. So a lot of times you'll see those levels shake out in the LOI as well. 



Richard Groberg  15:14

There are two transactions recently where the seller selected Jay to represent them. And in both cases, there were issues that came up on some of the things that Jay just talked about, where the buyer said, nobody's ever asked for that before. And why is that an issue. And by the time we got done, the buyers were changing their documents to reflect going forward, things that Jay brought up that no one had addressed. And some of the prior sellers were saying, Why didn't I get that and we need to change our documents. So there really is a level of detail and the interaction between purchase agreements, employment agreements, noncompetes equity, the parent, that if you're not watching careful and won't be synced, that can cause problems later on.


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Griffin Jones  16:44

Jay, I was gonna have you define controlling documents at risk of me sounding stupid. That's my job as the podcast host. Hopefully there's at least one other person in the audience that was wondering that, but please define controlling documents for us. 

Jay Stucki  17:03

Yeah, absolutely. I mean, first of all, you have to understand the there's the concept of the corporate practice of medicine. And many states have certain laws, summer force, different levels of enforcement. And so everybody kind of approaches buyers, from the corporate side approach things from what if the law changes. So that's kind of always in the backdrop that brings forward management service agreements, because usually there's going to be an management service organization or an MSO involved. You're going to have a medical directors somewhere, sometimes it's the seller, sometimes the management company wants their own medical director. And there's a level of control there. You have different mechanisms, such as succession agreements, assignment of membership interests, the revocable proxies, you can do control through loan agreements, and of course, through your employment agreement. And then there's the whole level of control, if you're going to say, Hey, I'm going to become a member. Now you're talking about, you know, joinder, to an operating agreement, LLC agreements, you know, so those are kind of the core documents, that you have to understand all of them, and know which tool the buyers are going to bring forth. And usually it's a multiple of the tools. For example, I just did a deal where we use irrevocable proxies employment agreements, and an MSA agreement. Another deal that we did back in now, I'm going to say, April, we use an management service agreement, succession agreements, an assignment of membership interests, it all those are all documents that are done on the front end. So for me, it's making sure that the physician understands how they're controlled by these documents. Because when it comes right down to it, right, the physician is responsible for the patient care. And the competing interest or concept here is, how do if I'm a physician, how do I do my job and give the quality of patient care I want if somebody else is controlling the organization, and you get into what is a clinical asset versus a non clinical asset, right, the physician, the Medical Director controls the clinical assets, which is really the patient care patient records. And then you have the non clinical assets which are owned by the company. You get into a situation where it's not a, let's say, a good, a good company, or they have a bad reputation, and I've had to help doctors get out of these situations. They can make your life miserable, right, they're gonna put in there on staff, you just lost somebody that was with you for a long time, but they want their own person there, or they're not going to buy you the equipment that you need or that you feel you need. And so, you know, sure, if you're the doctor, you say, wait a minute, you're affecting my ability to practice. In fact, for those who, whom some of you might already know, this is a big issue in the Northern District of California right now, it's federal court, where the Association of Emergency Medicine anyways, the group brought a lawsuit claiming that all of these controlling ancillary agreements that companies use to effectively control the doctor is being challenged as it is, in fact, the corporate practice of medicine because you've tied the physicians hands. Now, I think there's a delicate balance here that if you have people who understand the industry, such as you know, Richard, myself, then there's, there's a fair trade off being made. To see it another way. If I want to sell my practice, you know, I certainly can't take millions of dollars from my practice, and then expect to still control it and run it and do everything that I want.

Griffin Jones  21:14

Some people still do expect that, whether they realize that that's what their they'll say, they don't expect that, but they're expecting that, you know, when somebody is telling them what supplies they can order after and who what EMR they're going to use and who they can hire. Yeah, that's when they realize it, but when it's happening, they don't seem to, to always realize that,

Jay Stucki  21:37

Right. And my goal is not to try to tell the physician that it's gonna be, you know, this great rosy relationship and the honeymoons gonna go on forever, but rather makes sure that the physician or the sellers, are fully aware of these restrictive covenants of these controlling documents. Because at the end of the day, I assure you, the buyer, the practice management company, is going to control the practice, you know, if you're a physician, you know, gotta do depositions. And the other side always says, you know, almost right out of the gate, okay, Doctor, tell me, you know, what have we done that's affected your ability to treat a patient. And the doctor is not going to sit there and say, Oh, I can't treat my patients, because, of course not, they'd be committing malpractice. So it's, it's really about understanding a balance here, and making sure everybody's aware of what their arrangement is, and what they've negotiated, what they've sold, what they bought, and what their responsibilities are post closing.

Richard Groberg  22:47

And then lawyers like Jay, make sure that the documents accurately reflect what's been agreed to, in addition to the doctors understanding what they're getting into.

Jay Stucki  22:57

Sure. Let me give you an example of that. Thank you, Richard. You have some situations where they want the physicians held accountable for any losses. And my view on that is, if you're going to be held accountable for losses, or it could affect your compensation pool, because most of these agreements have some form of compensation pool, then the physician should have a level of say, in the expenditures under the MSO. If you're not responsible for losses, and it's not going to affect your compensation, then there should be a much less expectation of any say, as it relates to expenditures or how the MSO, you know, allocates costs to the clinic. So you there's that balance, where you really have to read the documents and see how much responsibility versus how much say you have, you know, they play off of each other.

Richard Groberg  23:57

That's a great example where the language in the LOI is important. If a doctor's post closing bonus is based on growth of earnings, then they need more visibility and say, into what's expensive practice. But if their bonus is based on how many retrievals do you do over a threshold, as an example, well, then it's not as important.

Griffin Jones  24:23

Am I correct in understanding Jay that the controlling documents themselves are not going in the LOI? It's simply refers to what controlling documents are going to be negotiated in the deal.

Jay Stucki  24:36

I mean, there's more than likely a reference to the MSA reference to an employment agreement, reference to maybe some of the high level restrictive covenants such as a non compete that you'd expect in the employment agreement. But usually the LOI is not going to get into P back or drag along rights that you would see under say the parent comp any equity ownership? So now it's more of a reference to the MSA and what falls out under the MSA. And I think that's critical where people like Richard come in. Because in the initial stages, the physicians look for someone to be able to say, Hey, can you explain the MSA to me? How does you know? How does the management services organization work? And am I really still going to be able to run my practice? Right? And, and, look, there are situations where the doctor sell their practice, and they run it just as they always did. And there's no or little interference. There's also situations where the doctor say, Oh, hold on, I don't like somebody telling me what to do. And we're going to put a stop to this right now. And the relationship deteriorates. So,

Griffin Jones  25:53

Richard, from your vantage point, does the multiple effect that so in other words, if if someone pays a lower multiple, are they more likely to let the physician Coast then if they pay a higher multiple times, because I'm just thinking if if I pay 15x, for something, I need to make sure that there is something different happening in their operations that or their their marketing that makes more patients come in, and they make more money? Because I need to earn that money back is from your vantage point is there does difference when people buy at a higher lower multiple how involved they are in dictating the operation? 

Richard Groberg  26:37

No pun intended, but that that question is pregnant with with the complexity of reasons why multiples are what they are, you know, multiples are typically higher, if there's a strategic reason for the buyer, or there's there's factors that make the practice, you know, the doctors younger, they're in a new building, they're at a high growth curve for multiple years. multiples are also dependent on, you know, working with one group that got an offer from a group that puts much less cash down upfront, and there's much more equity in the parrot, their trade off is okay, we'll pay a higher multiple, not necessarily paying a higher multiple, because we're going to do more to your practice post closing your different styles, Jay and I have worked with sellers who don't need a lot of help leave me alone. And that's okay. They're probably not a good fit for some buyers, but are for others. We've also worked with a couple of practices, businesses in the fertility industry, that were dynamic businesses growing, but reached a point where they absolutely needed management help. And the seller understood that in one case, it worked very well post closing and another case, the seller couldn't adjust to someone telling them what to do. But that didn't necessarily mean there was a higher multiple, because we're going to be more involved with

Griffin Jones  28:04

I want to go into some of these different major points and and try to find out how detailed they have to be in the LOI, let's go back to malpractice for a second does it have to be established in the LOI of if we're going to have a tail policy on the doctor, if the docs gonna be responsible for their tail, but how much of malpractice needs to be established in the LOI? 

Richard Groberg  28:29

Well, I think things like that. It's it's the eye of the beholder, whether it's material, my view, if it's material in terms of changing the nature of the practice, or an expense to the seller, or changes the essence of the practice. It should not be a surprise later on down the road. I mean, if, for example, if I've got practice with a seller getting ready to retire soon, and the buyer is requiring the change of malpractice carrier to tail, the doctor retiring pre closing, getting a free tail from their existing policy and not having to buy it so he'll say could save hundreds of 1000s of dollars. So were they a bit upset that they didn't find that out until a month before closing? Yes. But again, it's it's hard to know upfront what's material and whatnot material. But when you've got people like Jay, and hopefully myself, we've done a lot of things. We know the questions to ask so that anything that's likely to be material to the seller buyer is brought to the forefront in the LOI and not oh, by the way, somewhere down the road.

Jay Stucki  29:48

Now, let me add to that that Well, typically when you're talking about the traditional things, non non compete covenants or restrictions on territories Tell coverage, those tend to be pretty well understood and easy to negotiate with, as long as you have that expectation upfront, and you know, that it needs to be dealt with. I would say that, you know, we spend more time on, really the contribution and rollover or time as it relates to the role of the physicians when they become partners, how you bring in an associate physician, who participates in the compensation pool, what say you have an expenses, how the MSO is going to interact? Who's going to be the medical director? Those tend to be the more complicated negotiated issues than your traditional Oh, yeah, there's there's an expected now to compete, you know.

Griffin Jones  30:48

What, what level of detail, are you negotiating those things in the LOI?

Jay Stucki  30:54

Only, from the standpoint that it's a concern for either the buyer or the seller. And I think that's where Richard sits down. And he talks with this sellers and says, Okay, you know, let's talk about the warts. Let's talk about the problems, let's talk about your goals. And once you know, those, it's not that you have to necessarily expose them. But it allows you then to know what to work with, and what's important and what needs to go in the LOI and the you, you know, we're also concerned I know, Richard is, and I am, I don't want to start down a process where I know there's a problem. And then at the end, say, oh, save, by the way, no, you address it upfront. And, again, if you know the war, you know how to address it, and you don't catch anybody off guard. It is developing trust in my negotiations with opposing counsel, that we're all on the same page, we're all trying to get to the same goal. So it's not about hiding the ball. It's about vetting this upfront. And if it's important, as Richard says, we then included in the loi, if it doesn't look like it's important, then we back off. But the LOI is usually a compilation of five, six meetings between the parties through these discussions to make sure that everybody understands if there's an issue, let's get it in the LOI. And then, you know, the standard things, like I said, about the non compete, those tend to just be an expectation that everybody already knows how to deal with.

Richard Groberg  32:32

Yeah, Griffin, people who've never been through this before, the expression I use is you don't know what you don't know about the process. And when you've been through this, as many times as I have, as buyer seller, being sold to a group representing private equity, and now representing sellers, and with Jays experience, if we at least are aware of these issues up fraud, talk about it with the seller, make sure that the major ones are addressed, then we avoid the surprises and problems down the road. When people spend a lot of time and money that could blow up deals, create Hill will delay things, it's just it works better to try to address the major issues up front, having awareness having been through it a bunch of times of what the pitfalls could be.

Jay Stucki  33:24

The other thing too, is that you don't want to be I can't tell you how many times opposing counsel so well, that standard language that we use. And if you don't know that and have the level of experience than the variety of different deals that you've done in the fertility industry, you are in a very difficult position to be able to come back and tell them even though they know, be able to tell them why it's not standard language or why you're gonna reject their standard language. So yeah, you really need that detail, because that's a, I think, a tool that opposing counsel uses often. Oh, that's just standard, though it isn't standard.

Griffin Jones  34:07

I want to come back to standard language. It sounds like for your discovery of how material important these different major points for the LOI are, whether it's malpractice, non competes, post closing governance, rollover equity, equity and parent company working capital and controlling documents. It sounds like that is being discovered in a process which, you said Jay, might be five or six meetings. What does the first of those meetings look like? Actually, let's go prior to the first of those meetings. What needs to happen before the first meeting?

Richard Groberg  34:42

Every representative of seller does it differently. But in my scenarios, by the time the seller is ready to move forward and negotiate to conclusion and LOI, they've shared financial information they've had calls, they've discussed the buyer strategy and philosophy. They discussed what the seller is looking for in a partner to transaction, and then the buyer proffers that LOI, which then starts the negotiating process. That process itself a little bit like a marriage prenup helps define whether they're going to be major issues or not major issues and what the working relationships like. You know, again, if you've got a buyer that is more hands on, they're going to push some issues to make sure it's a good partner, the seller does it at the appropriate time, Jay gets involved to make sure that the non-lawyers aren't missing any things and significance. Again, by the time an LOI is ready for signature, as Jay said, besides all the pre LOI processes, there's 3, 4, 5, 6 meetings and discussions and back and forth. That gets hopefully gets everybody comfortable that yes, this is this is a good mutual relationship. And, and we've got enough documented that hopefully, the lawyers won't screw it up.

Jay Stucki  36:11

Now, but there's also an initial kind of, you eyeball a situation, are the sellers really ready to sell? I mean, that's a big question. And a lot of times, it's no guys, you need to get this in order, get this corrected. Or if you sell now, you're going to run into this kind of tax issue. So maybe you want to wait or maybe we get you a high enough multiple, that it's, it's worth that tax issue trade off.

Griffin Jones  36:39

So these 3, 4, 5, 6 meetings are we talking about? These are meetings that happen after we've decided, hey, there's probably a fit here where we're going to move towards proffering an LOI, or these are these meetings are just anything that happens before the LOI is proffered. 

Richard Groberg  37:00

The way I was defining it. There's a bunch of meetings, discussions, probably at least one person before the buyer says, I really want to buy you, I'm going to send you an LOI. They have an understanding of what the seller is looking for. When that LOI comes in there then are a series of calls, Zoom meetings, team meetings, discussions, that hopefully gets to a mutually acceptable ready to sign LOI.

Griffin Jones  37:31

So before we're even at that point of saying, Yeah, we're we're ready to receive an LOI from you. We're ready to proffer you, an LOI there, you that's when you're looking at financial information, talking about the buyers strategy and philosophy. That's that's when that stuff's generally happening. Richard, even before you decide that, yeah, we're, we're ready to move to LOI?

Richard Groberg  37:58

Yes. And every buyer is different in terms of the level of due diligence they do. All of them will visit in person and make sure there's good chemistry that want to see the facilities. They'll look at financial data, operating data, pregnancy statistics, valuate, the lab try to understand the nature of the doctors who's leaving, who's staying who were the driving forces. I mean, it's a big decision for the buyer. It's not just buying for the sake of buying, and who cares what the practice looks like, people want to look good. 

Jay Stucki  38:31

But I mean, you have ownership of the lab, that's a possibility comes into play as well. But the what Richard just covered, but keep in mind, there's a nondisclosure agreement in place. That's the first step.

Griffin Jones  38:47

So the the NDA happens prior to the financial statements being, 

Jay Stucki  38:52

Right out of the chute so that you can exchange information and not have to worry about any improper disclosures.

Griffin Jones  39:00

Okay, so that kind of starts you down the road of the, of where you might be going towards the LOI and Richard, is do sellers ask for buyers financial information as well like, show me Integra Med, how, how overleveraged Are you? Are people doing that? Can they do that?

Richard Groberg  39:21

Yeah, so that's that's an interesting dance. Typically, the buyer will make a presentation and share some financial information about the practices they have and their revenue and their their earnings. Pitch, typically, not until post LOI if the sellers are taking equity in the parent, where they give detailed financial information. Because if I'm the seller, and I'm taking 20 or 30% of my proceeds and stock and the parent, I clearly have to understand the economics of the parent. You know, what's their valuation, what are their earnings, what's their corporate overhead? What are the What are the limitations on just the CEO paying huge salaries? They're not being profitability? How much debt do they have? So, but that level of detail invariably happens post LOI somewhere down the road. Now pre LOI, but especially post Integra Med, all the sellers want to understand, hey, if I'm getting stock in you, I want to understand your story and what your plans are, and what's my stock, going to be worth someday

Jay Stucki  40:30

well, not only what the stock is going to be worse, but is there even a market to sell it, you have yet to remember, these are most likely privately held companies with some kind of VC backing. And it's not like you can just turn around and say, Hey, I'm going to sell my shares to anybody, you're going to have very harsh restrictions on your ability to sell those shares. And that's where we get into the estate planning component, right? If these, if this is a long time hold, or a long time play, I think that a seller needs to the ability to be able to put their equity into some kind of estate plan, you know, trust for their children, whatever, because it's not, like there's a quick turn, we're going to sell my 20%, you know, next year.

Richard Groberg  41:20

Jay does a lot of work with the sellers on that, because the reality is, to the extent they're rolling into the parent, yeah, they're deferring their taxes on that part of the sale proceeds. But they're, they're minority equity in a private company, that hopefully someday, somewhere in the future, will sell to another private equity firm or another one of the roll up groups or maybe go public. And if they go public, you're probably going to be restricted and not get to sell anyway. So people have to understand they're going to take that stock, and they're going to stick it in the drawer somewhere and hope, in the state or trust, and hope that someday, they merge it to somebody else or sell to somebody else.

Griffin Jones  42:03

So we've signed our NDA, we've looked at each other's financial information, we've assessed some culture vet, we maybe have done a visit and well, hopefully we've done a visit by that point. And we have done some a little bit of due diligence enough to say that we want to move forward with an LOI. What is that? Maybe? And maybe there's three meetings after that. Maybe there's six meetings after that. But what is the first or the earliest meetings typically look like? 

Richard Groberg  42:31

Post LOI? 

Griffin Jones  42:32

No, this is pre LOI, but after, after some of that earliest due diligence has been done. So it's after we we've looked at the buyers philosophy, we've heard their pitch, we've, they've seen our financials, we've determined there's a fit, we want to move forward, then when we start to build and negotiate the LOI, what does that first meeting typically look like?

Richard Groberg  42:55

They sent in an LOI typically, either to me or to the sellers and me. And often it's to me first so I could push back on things that I know from the seller's perspective, date to be modified changed, are going to be acceptable, I try to keep the sellers free of getting sucked into what I call the transaction vortex as much as possible. And at the appropriate point, we may have to get back on the phone with the sellers and buyers to discuss sort of issues that can't seem to get resolved. Sometimes it's not necessary. Sometimes it is,

Jay Stucki  43:34

The LOI is a negotiated document between the partners. It's not as if they send it over and say take it or leave it.

Griffin Jones  43:41

And so those we talked a little bit about though, is that often you're not in the, you're not having the buyer, or excuse me, the seller, look at the LOI until you've had a chance to take a look at it yourself. Why keep them out of the transactional vortex?

Richard Groberg  44:05

Well, sometimes they are they do get a copy. Sometimes they don't do my job and other sellers, representatives job is to represent them know what the sellers want, don't want and try, you know, they're seeing patients all day long. They've got their lives. And so to the extent I know what they're going to accept or not accept, I never make decisions without their input, nor does Jay. But my job is to go back to this buyer. And I've never had an LOI that was like, oh, this is perfect, we're accepting it. To go back and say, can you please explain this or we need to tweak this or you've got something from a prior document you forgot to take out or we've got these issues to discuss. It's always with the direction of my sellers, Jay is the same way but what I don't want to do and part of my job is to keep the sellers from getting so caught up in that process, that it distracts them from their, their business, distracts them from patient care and taking care of their staff. And then, I mean, most of my calls with my sellers are very early in the morning or the evening, or weekends, because they're busy with patient care and, and their staff.

Jay Stucki  45:24

Well, and the physicians want to stay busy with their patient care, because they're, you know, the the multiple is going to be used, you don't want that last month to drop off, because I assure you, they are going to make sure that their calculation is a rolling, usually a rolling 12 months. And they're going to take that up to the very last minute, any data they can have. So if there's a drop off at the end, because the physicians taken away from patient care, that's a drop off in revenues, that's going to affect the, what's used in calculating the multiple.

Richard Groberg  46:03

I've seen lots of transactions, Griffin, where sellers in lots of different industries didn't have a lawyer or an advisor working with them. And they got so caught up in the in the business of the transaction that their practice suffered, there started to be staff issues in affected their business, sometimes in hostile negotiations, that's a tactic. And then it affects the ultimate purchase price. Because the buyer comes in and says, hey, the last three months, your business has deteriorated 20%, it's not worth as much.

Griffin Jones  46:43

So you're talking about part of part of it is convenience, part of it is so that the physician is able to remain productive, but is there also a component of it so that they don't get too invested early on it. So if they start to invest so much of their time they start to be in every meeting, if they that they start to become too invested into the sale, and that gives the buyer more leverage. Is that is that it play at all?

Jay Stucki  47:09

I would say no, just from the standpoint that, you know, if if I don't think this is a deal that can be done at the end, I would have be upfront with the physician from the get go. And, you know, good advisors not going to get you to the point of an LOI if he doesn't believe that it's a good fit. And that's not only from the Richard perspective as a consultant, but from the attorney perspective. The last thing we want

Richard Groberg  47:36

 That continues all the way through to the closing

Jay Stucki  47:40

Right, the last thing you want is, you know, legal, your client telling their attorney, you know, what, what the heck did you get me into? And so, you know, I love it at the end of the day, when my clients come back to me and say, Jay, not only did you do a great job, but you benefited all the other physicians are in the group, because you saw things that they didn't it that the MSO recognize, they need to adjust that now benefits the hall. Boy, we wish they could pay your bill. But great job. And that's the goal. That's that satisfaction, what I look for at the end of the day, but that's in the forefront of my mind from the get go.


Richard Groberg  48:21

Yeah, Griffin from from an analogous situation an RE, who runs his practice has people in the practice who do their jobs better than they can that that facilitate or leverage their ability to holistically run the practice. When it comes to these transactions, with the hundreds of hours that Jay and other lawyers invest that I work on. They're trusting the experts to do what they need to do on behalf of the sellers. And but to make sure they never get surprised. You know, Jay Jay, invest hundreds of hours going back and forth with the lawyers. And it's his job to make sure that he knows what the seller will and won't do. And when there were major issues, explain it and make sure the seller knows what they're getting into on all these subtle, subjective issues. But if the seller had to do all that in his or herself, first of all, they might not have the expertise to do it, even if they think they do, but their practice would suffer. 

Griffin Jones  49:23

Jay, it might be unethical to enter into an LOI with more than one buyer. Is it illegal?

Jay Stucki  49:31

No. But typically, you're, you will not see an LOI that doesn't have an exclusivity clause. In other words, nobody wants to, you know, it's very expensive, very time consuming. I mean, you're talking about hundreds of 1000s of dollars on any significant transaction. And nobody wants to say hey, what do you mean? I'm one of three horses in the race. Right? So that's where the importance of the upfront work. comes in to make sure that that's the horse, you want to hitch your wagon to, to make sure. And of course, if you're the buyer, you want the exclusivity because you're not going to go down the road and have the carpet pulled out from under you at the last minute.

Griffin Jones  50:14

From your vantage point, having done a number of these deals, what percentage would you say of LOIs do not result in a deal between that buyer and seller?


Jay Stucki  50:24

I think it depends on the industry. In the fertility industry, I've never had one not go through. But I think that's because I try to team up with people like Richard, who we set the table before, hey, we know what we're getting into. And we're not trying to take somebody down the path of an unknown. And let's hope for the best. Like I said earlier, if I don't think I can get this deal closed, I'm going to tell you that upfront, when I get an LOI that's already been signed, as opposed to draft or, yeah, I study it very closely. I'll call Richard, I'll call the client. And I'll good drill down and go through the questions to make sure that I understand what was behind it. And there are representations that I've declined. So, you know, to the extent maybe that LOI didn't go through, yeah, that's a real possibility. But I wasn't involved at that point, because I never took the assign.


Griffin Jones  51:23

So that wasn't necessarily my understanding. You know, I wasn't in the RMA, New Jersey, Shady Grove deal that didn't happen, what it was, what was it seven years ago, or something like that. But there was almost certainly an LOI in place there. And I don't have specific details I'm inferring a lot. But something didn't happen there. So my understanding was that it was more common. Jay, it seems like it's it's not so common for, for parties once once the LOI is in place for for them not to do the deal

Jay Stucki  51:53

I'm sure there's a lot of LOIs that collapse I, I represent a different group of entities in a different industry that run into the same issues of licensing corporate practice of medicine type analogy. And yeah, there's LOIs there that collapse all the time. So I'm sure they're out there. What I'm trying to distinguish is that, you know, if you can separate the wheat from the chaff, you can pick and choose. And I've been fortunate that I'm able to pick and choose those deals that I believe are workable that will produce that I'm not wasting my clients time. And so I maybe I can't really answer your question globally. But from the standpoint of those deals that I I'm selected for, and that I want to participate in, in the fertility industry, I'm batting nearly 100%.

Griffin Jones  52:51

So we've negotiated the LOI at this point what needs to happen before it's finalized. So, you know, Richard has torn it apart, Jay has torn it apart. Now are all the parties brought back in to review the document together? Are you reviewing it with the seller separately? And then buyer's counsel is reviewing with them separately? How, what how is the how is the LOI finalized before everybody signs it?

Richard Groberg  53:17

Well, I'm in the negotiations go back and forth. And both parties at some point, reach a point where they go, okay, there are no more open issues. And then everyone gets final changes or reviews that make sure that everything that was supposed to be changed, got changed the way it should, and then everybody signs.


Griffin Jones  53:34

Do you all review that together, though? You know, in the same Zoom meeting, or the same boardroom, or that can just happen, as each line

Richard Groberg  53:42

Modern technology, DocuSign, or whatever your poison is.


Jay Stucki  53:46

And let me tell you, there's also an underlying thing that we look for, in these back and forth meetings on the LOI, and that's the sense of cooperation, is everybody looking for the same goal? Because inevitably, there's going to be some clarification that's going to come up under the LOI that needs to be vetted when you get into the due diligence and the definitive documents. And if you don't have that sense of cooperation when you're negotiating the LOI, that's kind of a red flag from the start.


Griffin Jones  54:21

I'm glad we zoomed in on the topic of LOI so today we could have gone a lot broader but I like as I have experts on more frequently to dig deeper in particular topics. And we spent an entire episode talking about the letter of intent, which I think is really useful for folks. And it also gives me about 90 different ideas for follow up episodes that we could have you each back on because any one of those major points for LOI could be its own episode topic, but I will let each of you conclude, what does our audience need to know about letters of intent before they sign one to sell their practice?

Jay Stucki  55:02

I think you have to be upfront with your counsel or your advisor as to what your real goals are, you've got to drop your guard, you know, if you are really wanting to retire sooner than later, that's absolutely critical if you have health issues, and you know, you kind of kept it kind of behind the scenes or private, you need to disclose that. And so, you know, with attorneys, you get attorney client privilege that attaches right away with advisors, they have their own separate agreements. But it really is important to understand the client, and what their goals are, what their concerns are, what the warts are. And if I have that upfront, I can get you a good LOI. Absolutely. And it may not be with the the buyer that you wanted. But take the fertility industry, you know, there's four or five, companies always looking for a good acquisition. And so you're able to shop and see who might be the best bet.

Richard Groberg  56:09

And I think some my perspective, Griffin, like I've said before, it's not the final document, but there should be enough specificity detail based on the buyer and sellers goals, that it's an important governing framework. So all the work that has to be done after, and it needs to be taken very seriously, it's a lot like getting engaged. People are going to spend a lot of time and money soon as that document's signed. And you don't want surprises down the road. You don't want major problems down the road. And as Jay said, hopefully by the time that LOI is fully negotiated, the parties have a good working relationship. There's still going to be issues, there's still going to be some battles fought, hopefully between the lawyers, but it's an important stepping stone to the rest of what will happen. And I'm still seeing problems in some deals that haven't closed yet, because the LOI was unclear on some things.

Griffin Jones  57:13

Jay Stuki, Richard Groberg. Thank you both very much for coming on to the inside reproductive health podcast.

Jay Stucki  57:19

Glad to be here.

Richard Groberg  57:21

Thank you, Griffin. Appreciate what you're doing to the industry.

Sponsor  57:24

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Email Courtney cbarrett@bundlfertility.com. That's cbarrett@bundlfertility.com. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health. Nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser. You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

189 The Latest On IVF Legislation, Coverage and Employer Benefits with RESOLVE CEO, Barbara Collura


In our latest episode, Barbara Collura, the President and CEO of RESOLVE, delves into the critical topic of expanding and protecting access to care. RESOLVE is making a significant impact in this area, and the key talking points from our conversation illuminate strategies, steps forward, and solutions.

  • Learn about RESOLVE's initiatives to expand and protect access to care and assist employees with insufficient coverage.

  • Stay updated on the New York State mandate, implemented in 2021, and its connection to fertility preservation legislation.

  • Speculate on upcoming Access to Care legislation, potentially involving IVF, in Oregon, Washington, Minnesota, or California.

  • Address concerns about IVF legislation in states such as Kansas, Alabama, South Carolina, Arkansas, and Georgia.

  • Explore fertility preservation and Onco-fertility Preservation bills, as well as access to care legislation, including IVF.

  • Support and contribute to RESOLVE's advocacy through events, memberships, and funding.


RESOLVE: The National Infertility Association
Ask Rebecca Flick: rebecca.flick@resolve.org

Transcript

Barbara Collura  00:00

We had a really interesting year and 2023 with more states passing fertility preservation. So this is for iatrogenic cancer patients, for example. So we saw Kentucky, Montana, Louisiana and Texas. Think about that. Kentucky, Montana, Louisiana and Texas, all pass legislation, mandating insurance coverage for fertility preservation. Each of those bills and laws is a little bit different. They are not all the same.



Griffin Jones  00:51

Expanding and protecting access to care. That's what I get into with my guest today, Barbara Collura. You know, her as the president and CEO of RESOLVE, if you're in the United States, resolve does a lot for you. So I make Barb tell us about what resolve is doing for expanding access to care how they use their coverage at work resources for advocating for employees who don't yet have access from their employer, they don't have that coverage or don't have sufficient coverage, specifically, how resolve helps the employee and the human resources department, we talk about states that have expanded access to care. I have Barb give us an update on the New York state mandate that was passed in 2019, but didn't go through until 2021. And then how that links up with the fertility preservation that had passed there. She talks about states like Kentucky, Montana, Louisiana and Texas which have passed fertility preservation bills or uncle fertility preservation bills passed for some headlines that we might be able to see in the coming months who might be passing big access to care legislation, not just fertility preservation, but IVF. Maybe it'll be Oregon. Maybe it'll be Washington, maybe it'll be Minnesota or maybe this fall. It'll be California then Barb talks about protecting access to care. I get us to speculate on a situation what happens if there's mass layoffs will resolve have to work to keep these employer benefits are the people that they advocate for? I asked her to weigh in a year after the doctor's decision. What sort of legislation were they most concerned about? Sounds like there was language in bills that it would be dangerous to IVF in states like Kansas, Alabama, South Carolina, Arkansas and Georgia. Barb said none of those passed when I asked her if any bills passed that restricted RT within the last three years. She said no but she does put an asterix on a bill that passed in Wyoming and she talks about that and we conclude with me calling you out a little bit depends on which camp you fall in. I might be highlighting you but I generally call out different categories of clinics and industry side companies and how they can be supporting resolve you can if you do business in the fertility space in the United States resolve does a ton for you. And there's a ton of different ways for you to meaningfully contribute, you can email me and I'll connect you to resolve or you can go to resolve.org whether it's their advocacy day their walks for hope their professional memberships their night of Hope gala are other ways to fund and provide resources for their support and advocacy services. Invest in them because they're protecting you and tell them Grif sent ya. Ms. Collura, Babs, Welcome back to Inside reproductive health.


Barbara Collura  03:17

It has been a longtime grift. And I love your show. And I'm honored to be back and thrilled to be here. Really,


Griffin Jones  03:24

it's been too long. So I need updates about what's going on in the resolve world because you guys touch everything are seemingly everything from my view. For those that don't know, the way I learned about resolve in the first place was 2014. With starting a social media company, for doing social media for fertility clinics, I wanted to know from the perspective of folks that were still going through their journey or some folks that hadn't worked out. I emailed every peer support group leader in America from resolve got a bunch of them to talk to me. And then I got an email from resolvers saying, Hey, who are you? Let's talk that's how I got to know you guys. But it started all from Wow, they do this patient support stuff. And then I started becoming interested in results for my clients because it is useful for patient acquisition and retention to have resolved support. Then I met you in person in 2015 and DC when resolve and ASRM did a combined advocacy workshop. And so resolve has done a lot does do a lot what's new, though, like what what what's particularly grabbed your focus in the last two years,


Barbara Collura  04:36

access to care for sure, access to care and so Griff when we look at our community and we look at the work that we do, we are constantly surveying our community. We're constantly asking people, What do you need? What's the biggest pain point for you and your family building journey? What are the things that result can be doing? How are you accessing our store? resist. So those are all standard things that we continuously ask the community and access to care over and over and over and over is number one, number one, number one, number one. So it's always been


Griffin Jones  05:13

that way for you always


Barbara Collura  05:14

been that way. And so we've just amped it up. I mean, we have more going on. And we continue to do more. And then the Supreme Court makes a decision, like the dobs decision, which in June of 2022, really made us have to think about protecting access to care in a very new and different way. So we kind of look at access to care in two, actually three big buckets. One is access to emotional support. We know that having emotional support on your family building journey is very beneficial. There's data that shows it keeps you in treatment longer, and helps you make better decisions. So we put that under the Access to Care bucket. And then we look at how do we expand access, because there's far too many people that don't have insurance don't have benefits don't have a way to even access the family building option that they want to use. And then the third bucket is protecting. And we've always been doing that. But with the dogs decision in 2022, we had to look at it in a very different light. So we are just amping all of those things up. When you asked me what's going on the last two years, that's that's where our huge part of our focus is.


Griffin Jones  06:35

So when you say expanding access, you also say you've got you've got a lot more going on what's been the lot more that you've had going on with regard to expanding access,


Barbara Collura  06:46

I would say it's in two areas. One is just state mandates, looking at our work in state mandates, this year 2023, we've been very, very active in not just two or three states, but like six or eight states. And we've seen fruits of that of that work, and then could go into detail on that. And then our coverage at Work Program, Griff This is where we recruit and train and provide resources to people to go ask for better benefits with their employer. And it's just it's like, every month we hear of another company that's added benefits. And it's because somebody who used our resources asked for it now, not every company that's adding benefits, had somebody use our resources, but we do track the people who who use our resources, and who avail themselves of our support, and, and so forth as they talk to their HR folks. And a lot of times we're talking to the HR folks as well. So those two areas, just like going gangbusters. I mean, they really are


Griffin Jones  07:55

I want to ask about the six or eight states. And then I also want to talk about that expansion of the employer coverage. You did mention protection. So let's talk about that for a little bit. And we'll shift back to expansion, where a year out from the doctor's decision now, there has been a lot of concern. And what I'm interested in is specifics what specific I had Igor Brusilov on the show, and he said something that I think is great wisdom, which is anytime legislators start putting pen to paper, you should be paying attention you should be concerned. So there's concern that could happen anywhere, but what specific states what specific pieces of legislation have either were most concerning, and we're not resolved or are coming up?


Barbara Collura  08:40

So we saw a number of states. Well, first of all, let me just kind of backtrack, we look at a bills, and we read those bills, and we either put them in like a category that says there isn't anything in this bill that's going to impact access to IVF or ectopic care or miscarriage care, just because of how its worded. We're going to put it over in this pile. And that's not something that we're going to focus on just now. And then there's the pile of bills that we read and we're like, there's concerning language. There's vagueness or there's some language that's wide out very, very scary. So we saw bills, specific bills South Carolina, Alabama, Kansas, that Wyoming that were very concerning. We saw concerning bills in states like Texas and Georgia. The one the ones that were really really really awful. Were South Carolina, Kansas, Alabama. There were there was a bill in Arkansas. So we saw language that was such that they were defining an unborn baby, not a person, they were defining an unborn baby. And that's the unborn child story. They were defining an unborn child as beginning at at fertilization. And then in the bill, there wasn't any language protecting any other kind of care. So these sometimes are shorter bills, that kind of language. The one in Kansas had some really odd language about artificial insemination. There, so it actually went towards more on the treatment side. But certainly the bills that I just referenced, we were concerned about how they were defining an unborn child when life began. And then zero language that protected anything that's done in an IVF clinic, as well as protecting our a woman who may need miscarriage care or pregnant person may need ectopic pregnancy care. So I will say that none of those bills advanced for a variety of reasons in each of those states. And so we read those bills, and we put them in the box of these are really, really bad bills.


Griffin Jones  11:18

How do you find out about when these bills are coming forth?


Barbara Collura  11:22

We pay for a bill tracking system, which a lot of organizations do, ASRM has one. Some of the other organizations that we partner with on coalition work, have build tracking systems. Some organizations not resolved but some organizations that are in the reproductive health space have state entities all over the country that have lawyers and lobbyists who track stuff and because resolve is part of several different coalition's we also share information. But we have a bill tracking system that we paid for. It's only as good as the keywords. So it doesn't read the bill for you, it doesn't flag it as bad. We have to still go through it and read it and determine through our own resources, our own staff, is this a bad bill or not? And then oftentimes, because we're part of these coalition's we'll trade information. So for example, on Alabama, we reached out to some folks on the ground in Alabama, we got some feedback from a coalition that was fighting all of the anti abortion bills, we got on a phone call with them, we walked through this particular bill, they were able to tell us tremendously valuable insight information on who the bill sponsor was how this bill was being viewed in the chamber, how many more weeks they had, what's the legislative process, oh, this is going to be assigned to a committee chair, who's not going to do it, anything with it, because there's this other thing going on things that you you and I would never be able to figure out on our own what's going down in the state capitol of Alabama. So that's the kind of work that we have to do. Oftentimes, for each one of these bills. I also try if we don't have access to a paid lobbyist, and we could talk a little bit about that, and try and see who might, who might have a paid lobbyist, and then talk to ask that organization. If I can talk. I've done that a couple of times this year, I've reached out to organizations and I've said, Would it be okay if I talk to your pay lobbyists and ask them some questions, and that's very difficult because they're paying that person and now I'm asking for some services. But oftentimes they'll say yes. So it's gathering as much information. We ended up hiring somebody in South Carolina. But I knew of a lot of other resources through our partners, through our pharmaceutical partners through other organizations that I could go through and ask them to provide us with some insights.


Griffin Jones  14:11

This might be a lobbyist one on one question, but do your lobbyists if you're talking about state houses typically come interest state? So if it's a Nebraska Bill, you want to have somebody in Nebraska or their or their lobbyists that cover all parts of the country?


Barbara Collura  14:26

No, you want somebody in that state capitol who just works in that state capitol and knows that very, very well. The person that we hired in South Carolina, we didn't actually hire this firm to do lobbying. But they are a registered lobbyist. We hired them to do Bill monitoring. It's a little different. We didn't authorize for them to speak on our behalf, which is what lobbyists can do. They were on the ground. deeply, deeply involved in the day to day operations in the South Carolina legislature which is convoluted to, to put it nicely. And we needed that. That high level information that was accurate and timely. And that's what they provided to us.


Griffin Jones  15:13

So South Carolina, Alabama, Kansas had some scary wording in their bills where those ones didn't advance. Were there any bills in the last year that passed in any state house that that hindered the capacity to do art?


Barbara Collura  15:31

I'm going to say no, with an asterick. So Wyoming passed an abortion law, it was signed into law by the governor. And it has some disturbing language in it. But it was very clear that that bill was about a pregnant person. So that's another area that we would look at in who this bill impacts, because that's not going to impact IVF if it's very specific on a pregnant person, but it had some language in it, that I would not have preferred to see. There's no Rei clinics in Wyoming. And so nobody is getting access to IVF in Wyoming that we're aware of today. So and I wouldn't go even go so far as to say that with that law in place, IVF is impacted. We just wouldn't, we just wouldn't would be careful about if there were clinics in Wyoming. Not that they couldn't do what they needed to do. It would just be an extra effort to try and determine, make sure that they are complying with the law. Given that that's not the case right now in Wyoming, my answer is still no, we didn't see anything that passed in 2023. That is x that is impacting negatively impacting people's access to IVF or rights over their embryos.


Griffin Jones  16:58

I don't want to take us on too much of a tangent but how does this affect third party if at all,


Barbara Collura  17:03

it affects third party surrogacy, if you're using gestational surrogacy, you have to do IVF. If you are doing donor egg, you're doing IVF. If you are doing donor sperm with artificial insemination probably doesn't impact it. Because what's the focus is traditionally on? What is an embryo? Is it a is it a person or not? And when does life begin? So you'd have to look at what the medical procedures are, it could impact genetic testing, though, it could impact embryo cryopreservation. A could impact other things that we might want to see down the road in terms of any kind of manipulation of the embryos in the laboratory.


Griffin Jones  17:46

I want to come back to some of the legal advocacy when I asked you about how you overlap and work with other groups, but still within this sub theme of Protecting Access to Care seems mostly to be on the advocacy side, because the employer side has mostly fallen into expansion. Now. I wonder if we do see a big contraction in the economy, if you'll start to find yourself in the protecting of the employer benefit side. So you know, when I see these tech layoffs, 1000 people here 500 People here, have you seen any retraction in fertility benefits yet?


Barbara Collura  18:26

I don't know that I would necessarily know that if they are. There might be a new story about it. There might be something you know that we hear from one of the third party benefit providers.


Griffin Jones  18:39

I guess there was Twitter, right. That was in the headlines, I think yeah.


Barbara Collura  18:42

And sometimes I do my best, we do our best to track that down. I don't believe that every news story is accurate. Shocker. So because we see so much of what we know, as fact, and then we see it in the media, and we know it's wrong. Got a specific for us. Now, there's so many, I just would I would, I would I would say that with without really good data. I am not in a position to say whether fertility benefits have contracted currently, under our current tech layoffs and that sort of thing. I simply do not know enough.


Griffin Jones  19:24

I wonder if that's something that you'll have to consider in the next couple of years? I hope not. I don't know. It seems like that hasn't been the case so far. When I do my episode with Ravi gota, and many Shuguang about chat GPT and we talk about how much that's going to take over in the art space. It's also taking over a lot of the tech space. I think it's going to take over a ton more in the coming years. And and I hope that doesn't mean mass layoffs. But it could and if it does, I wonder if that is become something where You have to help people make the case that their, that their benefits aren't taken away.


Barbara Collura  20:06

Whenever a company, any kind of company is looking at their financial sustainability, I'm sure they're looking at all different possible ways that they can cut costs. And I would hope that they would look at their full benefit list and determine you know, how that impacts their current employees. Remember, though, that infertility benefits have grown now, way beyond financial and tech, you've got Starbucks and Lowe's, Home Improvement, and you've got hospitals, you've got municipalities, you've got teachers unions. So we have gotten to the point where there probably isn't an industry that isn't currently offering these kinds of benefits. So I would, I would hope that there would be opportunities for people to find jobs in other places that would have those benefits. We know their recruitment and retention tool. So if you are still looking for talent, or you want to retain your talent, it's an excellent benefit for for those reasons. So you're absolutely right, though, we haven't had an economic downturn. In a world where a lot more companies are offering this benefit. So we don't have any data to see how companies react, I guess I would want to look back at 2007 2008 and determine if companies were who were contracting, if they did eliminate paid leave, or you know, other kinds of you know, other if they reduce their vacation or whatever it was in terms of benefit design for their employees, I just found out


Griffin Jones  21:49

my company did in 2008 2009, they did a whole bunch of crap. And it wasn't a great, they didn't have a lot to begin with either. But we're in a different world. Now. That segues us back into the by the way, it wasn't my company, it was the company I worked for, didn't own my own company when I was 23. When we segues us back to the expansion of care. How are you helping employees make the case to their employers? And is it is it employees that are coming to you first? Are you networking with HR groups? And and and the companies are coming to you sometimes? Or is it employees that are part of the support networks of resolve and they're coming to help me find a way to get my employer to to extend this to other people?


Barbara Collura  22:37

It's the latter. When we looked at the work that we were doing on the advocacy front, we felt like we had done such a good job of recruiting and training people to advocate to their state legislator or coming to Washington, DC to advocate for their federal legislator. When we looked at employers, we thought why can't we do the same thing. But instead of going to their state capitol, they literally walked down the hall, they EHR, and they advocate that way. So we took our years of advocacy, grassroots advocacy experience and segwayed into this coverage at work, we don't have the ability to go top down. So well, that sounds like the natural way. That is not a way that worked for our organization, we felt that we had established a brand, and a trust and a reputation amongst the grassroots that we knew what we were doing. And so we put together a program called coverage at work. It has resources and toolkits for both employees and employers, but our marketing and outreach and the majority of our work is talking to employees, we find them just how anybody finds resolved and how anybody finds our support groups. And we also know that many many people are referring people to this we have many of the SARC clinics who are telling their patients at the point of care you and I know how clinics have financial advisors how they have have the people who sit down with the with the patients and talk about their insurance or the cost. And you and I know that clinics do a such a great job of understanding who's in their community, and what kind of benefits they have because they've had patients from all the big companies in their in their community, and they can easily say to someone I know where you work. I can tell you right now, you don't have any benefits. However, here's a piece of paper I'm going to give you there's an organization called resolve and they have this great program and it'll help you learn how to potentially advocate in your in your company. We don't want the clinic to feel like they have to do that. So we have so many ways Gref that people come to us and find that program. And then originally it was really just If the employee toolkit and then we realize what if they go down the hall to HR, and they make the ask and then HR is like, what do I do? What do I do now? I don't even know what you're talking about. So we are creating an employer toolkit. And most of the employers who are fighting that are because the employee has said, here's this toolkit, by the way, don't believe me, here's all this information. And then we we have an opportunity. So we have modelled benefits, we have a lot of costs and financial data. Of course, we have medical data in there as well. And it really arms, in my opinion, the HR professional to begin to do those discussions and research at a, at a higher IQ level. Now, they have now some knowledge and familiarity, they probably have ways to ask questions of their broker, maybe their existing provider, and so on.


Griffin Jones  25:54

So how do you work with the employer carve out companies?


Barbara Collura  26:00

So are you talking about that what I call the third party benefit providers, which


Griffin Jones  26:04

Proginy, Carrot, Maven kindbody,...


Barbara Collura  26:07

We work with them, like any corporate partner, so if they want to come tonight, and hope if they want to sponsor one of our programs that are part of our standard, a sponsorship, we do that, in terms of other ways that we work with them. I like to say that the work that we're doing with employees and employers is creating a lot of awareness about the need for these benefits. And I'm hoping that it's generating demand for those benefits, because I want more and more and more employees to be talking to their employer, whether it's through anonymous surveys, whether it's direct conversations, I want HR people all over the country to be like, Oh, my God, I heard from another employee about this bet the need for this benefit, I keep hearing about this over and over and over, that's generating to me and what they then do with it, and how they get that filled, that need filled within their company, we don't get involved in


Griffin Jones  27:06

is there a reason you don't get involved? Because I'm thinking if I'm on the sales team for one of those companies like man, I want to sponsor that Toolkit. I want my name at the top of that toolkit. And then I want resolve to maybe pass that email from that person along to me, is there an opportunity for them to


Barbara Collura  27:23

we don't do any sales, sales referrals, we don't have a sales pipeline business going is a nonprofit, we are very careful about our brand, about being unbiased. And about providing objective fact based information. I will say if a if an HR person contacts resolve and says, I heard there's third party providers, can you give me a list, we'll give them a list. We have everybody listed on it. And so so we will provide a list but I'm not going to give go any further than that. And resolve is not a sales in a sales pipeline position. And I think that, you know, we're here, I can tell you right now grip, if I was to do that, I would have to know every single thing about those company and their products and their pricing and be able to be in and that's what brokers do. That's what other folks do. And I'm not we're not in a position as that patient advocacy organization to get into that business.


Griffin Jones  28:31

Maybe they could buy some tables that night of hope for some HR associations, though, that wouldn't be a bad idea.


Barbara Collura  28:38

You know, they can do they could do a lot of things I we do we do research studies, we've done speaking, I've been on panels at some of those HR things where I talk about resolve, and it's one of those benefit providers who's also on the on the stage speaking. We're happy to do any of that kind of stuff, any opportunity to bring awareness to infertility, bring awareness to resolve, and mostly bring awareness to this these tools and resources that we have. I'm all for it.


Griffin Jones  29:08

So that's the employer expansion, part of expanding care. How about the state mandates? I think you said there were six or eight in 2023. Who who's in that group.


Barbara Collura  29:19

We had a really interesting year in 2023, with more states passing fertility preservation. So this is for i atherogenic cancer patients, for example. So we saw Kentucky, Montana, Louisiana and Texas. Think about that. Kentucky, Montana, Louisiana and Texas, all pass legislation, mandating insurance coverage for fertility preservation. Each of those bills and loss is a little bit different. They are not all the same. So for example, in Texas, it's Just for cancer patients who can access this benefit? Remember, let me just back up insurance one on one here graph. When you pass a state mandate, it's only impacting people who are covered by certain kinds of plans. It doesn't cover every employer. It doesn't cover. The companies that are self insured doesn't cover federal employees. So it covers a segment of the workforce, but not all. In fact, there was a great study that Boston IVF did, oh, my gosh, three or four years ago. Now, Alan Penzias, who was one of the authors. And they did a study in Massachusetts, which has the best insurance mandate. It's been around for 30. Some years, the percentage of people who were caught of their patients who are covered under the mandate, it was about 30%. So that gives you a sense. So Kentucky, it's only they're only allowing coverage for freezing of sperm and egg, not embryos. So each one's a little has a little different flavor to it. So we saw those come in. And the Texas one has been around that bill's been around for a few years, Montana, Louisiana and Kentucky. If I'm not mistaken, Griff, I think this is the first year they were introduced and the laws and the bills passed. It's pretty amazing. And then we did. We did IVF and fertility preservation bills in Oregon, Washington State in Minnesota. And then we're still working on an IVF only bill in California because they did fertility preservation a few years back.


Griffin Jones  31:42

So for those states like Texas, that it had been in, you said that Bill had been in the legislature for a couple of years. Was it that exact bill? Was it just a different version of similar bills that had popped in?


Barbara Collura  31:59

That's a great question. I don't want to say exactly my light. I will i My assumption is that the thing that changed this particular year was that it was just going to be for cancer patients. We go in typically with broad model legislation. Texas, we've had a fertility preservation bill for three or four years now. And each time it gets introduced. Yeah, there's little tweaks that I always made to it so


Griffin Jones  32:29

well, that so that was part of the question I'm really after is what changed to get that passed this year, if it had been before the goal line for a couple years, what what actually got it through this time,


Barbara Collura  32:41

sometimes it's a procedural thing. Some states have requirements that if it's an insurance mandate, it has to sit for a year and go through some kind of cost study. Sometimes it's as simple as who's chairing a particular committee where a bill has to get through like a rules committee before it hits the floor. And that position changed in in a particular state legislature. It's not always, I would love to say it's Oh, because we got more sophisticated and we were smarter, it may be little things that are completely out of our control, in terms of why didn't pass the year before. And then, you know, the stars and the moon line this year, for whatever reason, there is no rhyme or reason to, to be able to say this is what happens every year in every state and why it doesn't. And why it does move


Griffin Jones  33:37

is that generally the strategy to start a little bit broader and then to whittle down, why not the I because I can see, I can see both sides. On one side, it's called anchoring and negotiating, ask for the pony get the puppy. And if you ask for the puppy, you get the goldfish. So So start with more, but on the other and I could also see fertility preservation for onco. fertility preservation being fairly easy to pass that's going on a bunch of assumptions on my part. So I could be wrong about those assumptions. But you know, maybe you get more past and you start to build relationships in there. And then it becomes easier to get other things introduced. Talk to us why the broader first as opposed to the more specific first.


Barbara Collura  34:19

It's a it's a strategy conversation with the bill sponsor with the really the mood and the sentiment of that particular legislature, who might be chairing a particular committee that this bill has to go through and what do they like to see and not like to see? So our approach is always with our bill sponsors and champions is to go in with our model legislation. And then right there at that stage, you're going to start seeing changes being made based on what the bill sponsor and the bill champion are, are taking into consideration from their perspective. But our ask is always Are model legislation. And and then to your point like we saw this in Washington State this year, which the bill IV a bill did not advance. But they wanted to start taking things away. So one committee, and the bill sponsors introduced the big bill. And then they started to kind of want to whittle it away. And that's where we might say, Okay, we will still support this. But if you go below this level, if you start really eliminating things, then we're going should not support the bill. And then we will be asking our bill champion, to withdraw the bill. And that has happened. So not in this case in Washington State, but it has happened in legislation across the country where we have seen something get whittled down so much that we want to kill it, and we get killed.


Griffin Jones  36:00

How is the New York state mandate going was that 2021 That that was passed,


36:06

the mandate passed in 2019. Surrogacy became legal in 2020, the New York state mandate while it was passed in 2019, it didn't take effect until it was January 21. So and that particular piece of legislation is kind of interesting, because it covered IVF, in a very limited market. And then it covered fertility preservation, in that same market, but in a couple of others, as well. So the ivy that the fertility preservation mandate actually covers more people than than the IVF piece.


Griffin Jones  36:48

So when you say, a limited market, what do you mean by market,


Barbara Collura  36:53

in the case of state mandates, they're only for the fully insured market. And in the fully insured market in a state, you have the large group, small group and the individual market. And so state mandates can only apply to those three markets. And when I say large group that's in the fully insured market. Those are companies that are generally 500. At last, once you start getting even above maybe 250 employees, for sure, 500 employees, you become self insured, and then state mandates do not apply. So in New York, just to be very granular here, the IVF piece is only for the large group, fully insured market, the fertility preservation piece, they pass that law, and it applies to the individual, the small group and the large group fully insured market in New York. So


Griffin Jones  37:50

more people, I imagine you're in a number of different states, maybe ones like New York, trying to get them to provide IVF coverage for more people. As you mentioned, it's the case in California, we've got fertility preservation coverage, but you're trying to get IVF coverage, who's closest, as far as you can tell, what what should we expect the next big headlines to be? Can we expect any big headlines in the next coming months,


Barbara Collura  38:14

California is getting closer to passing IVF mandate. That's a huge market, as you can imagine. So they get closer and closer every year. That California is in session each year until around August. So we won't really know until, you know, August or September of 2023, how the year went in California. And then in 2024, we will be back in Oregon, Washington and Minnesota. And we got very close in Minnesota. I would I would I would hope that that would be a state we have governor who's an IVF. Dad got two kids from IVF. He's been very, very wrong. If I remember correctly, it is mine. That's gotta count for something. Maybe. And then we've got legislate both legislative bodies, their house and Senate, where there's a lot of champions, Washington State, we have phenomenal advocates. We have phenomenal advocates in Minnesota, Oregon and Washington as well, and just really committed champions. So that's, you know, that's half the battle is getting people excited in that state and keep them engaged. And we have gotten in all those states.


Griffin Jones  39:32

I think it was very nascent. And it was probably just someone introducing the idea. I don't know if it ever even got voted on, but I think it was Connecticut where they were talking about having IVF covered by Medicaid. Do you see that happening anywhere in the next year or two,


Barbara Collura  39:49

but we have seen fertility preservation covered in Medicaid and that was in that's been in Utah, so I could see down the road that being a case, we do have a federal bill, where cancer is being cancer, fertility preservation for cancer would be covered by Medicaid. And that's a bill in Congress. So I could see that probably being the first kind of thing being covered more widely, that that's going to be several years down the road.


Griffin Jones  40:24

Is that better or worse? For any reason? Let's use the Utah example fertility preservation being covered by Medicaid, does that expand it to more people? Or does it exclude the people that are in the other market


Barbara Collura  40:35

groups, it just expands coverage, it expands coverage in a very big way, and expands coverage to people, Medicaid, or people who are lower income. And so the chance of those individuals being able to like will take fertility, preservation, fertility preservation to preserve their fertility before a cancer treatment. That's not available to them, you know, they're not gonna be able to pay out of pocket for that. So this is hitting an audience that is very much in need of that. It doesn't hurt any of our other advocacy efforts. If we see a state decide to have Medicaid, for example, cover fertility preservation, that's a very good thing.


Griffin Jones  41:18

We dug in a lot to the expansion and protection of care both on the employer side on the advocacy side, this has you in the sphere of other groups as well. So there's SRM there's DRS for fertility, there's other nonprofit groups and and probably other agencies, how do you? How do you overlap with them? Where do you where do you where do you converge? Where do you diverge?


Barbara Collura  41:46

The key to advocacy is having a coalition of equals where everybody's bringing something to the table, and that are all aligned on our goals. And so that's what coalition's are, there's hundreds and hundreds and hundreds of coalition's of advocates who will work on different issues, let's say to the US Congress, when we go into a state we're looking for, who are our allies in that particular state who can align with our goals? Who brings something to the table that we can't bring? It doesn't really, it's not really advantageous for us to go in two states where it all us, Massachusetts, they are trying to get fertility preservation passed in Massachusetts and resolve New England is there. They are taking lead on that. If they need something from us, so let us know. But we're not going to play in the Massachusetts State Capitol. Why would we we're not bringing anything unique or different to the table and resolve New England is right there. So that's the kind of work and thinking that you have to do. We have a coalition alliance for fertility preservation, resolve, ASRM. And then faring pharmaceutical and EMTs thrown out the five, those five entities three of us are nonprofits to follow up. We've been working together for many years, to the point where we plan out what states we're going to be working in together, and how we're going to work together. It's very collaborative, it's very transparent. We make decisions on who's going to hire a lobbyist here or there where and how we're all going to work together. And because we've now been doing it, and where's a such a high level, a trust and professionalism, it works extremely well. So I will tell you, though, we look for partners in that state, one of the things that's really helped in California this year is teaming up with the California equality. So this is the LGBT group that's very prominent in Sacramento and in the state. And they became a champion of this issue, and it became one of their top issues for their legislative agenda. So they are we are on all our coalition calls with them. And it's been really, really fantastic, as well as other groups. So depending on on what we're doing, I'll give you a great example in Minnesota because you talked about that being my home state. We did an advocacy day back in April. In Minnesota and St. Paul and the Leukemia Lymphoma Society, advocated alongside of us. They had their staff, they had advocates, they made this a big issue. They have staff in every state capitol leukemia, lymphoma society does, I don't paid staff. They were all there with us participate in our advocacy day and did everything they could to help get our legislation passed. So so that's another example of what we do so coalition's are really the key, and that's how we do the work that we do. I will see you mentioned doc As for fertility, they are great at getting the word out about our particular legislation and helping, you know, we say to them, Hey, there's this hearing in Oregon or this hearing in Washington State, can you help or we need people to register for advocacy day, can you help and they are great about getting the word out. And then they're doing some things. There, there were a 501 C three organization as his ASRM as his alliance for fertility preservation. So there are things we can't do legally, as as a nonprofit organization, as it relates to lobbying, I can never endorse a candidate, I can never raise money for a particular person who's running for reelection, I can't even tell people how to vote. So doctors for fertility has the ability to do


Griffin Jones  45:49

more of those kinds of things. What haven't I asked you, we've caught up a lot about what resolves into and you're into a lot resolve touches pretty much every angle of this space, at least as far as patients are concerned. What haven't I asked you,


Barbara Collura  46:06

when I look at your audience of this podcast, it's people who work in this field, it's professionals. It's people who care deeply about the work that they're doing, to advance care for, for for people. And whether they're a doctor, whether they're a farmer, whether they're a CEO, genetic testing, I mean, I know who I listened to your podcast. And I know a lot of your guests. And they are folks who are our, our big supporters of our organization. But when I, when I talk to the audience of people that that listen to your podcast, oftentimes, they are unaware of how small we are, in many ways. And you were to when you first got to know us, because you're a victim


Griffin Jones  46:53

of your own success. In that sense, you're a victim of your own hard work in that sense, like you, you appear much larger, because you're all over the place.


Barbara Collura  47:01

I don't want to minimize the work that we're doing by saying, you know that we're small, that's not at all what I'm saying. What I hear oftentimes is physicians feel that we are well, well well funded, because we get all this money from pharma. Pharma feels like we're well supported. Because we're getting all this money from the doctor, there's a little bit of that everybody's kind of point and patients who say, I don't have any money, I'm not giving you any, I gave it all to farm and I gave it all to my dad. So everybody's pointing to somebody yells, and it's surprising. I hear this over and over and over from people who, when we when when a let's say a doctor joins our board or somebody, you know, starts supporting us. And they're like, Oh, my goodness, I didn't, I didn't realize that, that you guys, I thought you were like a $20 million organization. And I think that that people are surprised at what we're able to accomplish with our budget, we're incredibly good stewards is you know what we do, but we need to do more. And this is what, and it's not because I want to do more, because we want to have, you know, more staff is because our community deserves more. And they're not getting everything they need. I don't want to be doing this for 20 more years, Griff, I want to be done. Wouldn't it be amazing in five, six years, we tied a bow on this expanding access piece of it. And we we accomplished what we needed to accomplish. That's going to take investment and money. If we want to continue to do a couple of states a year and I'm still sitting here in 20 years. That's not helping our community. Do you know we have people who come to advocacy day, year after year after year, and you know what they tell me grift they say, My God, it my daughter, or my son who I've worked so hard to have is facing the same challenges that I'm facing shame on me. Because this sucks. And I can change the status quo for the next generation. But let's get it done. I want to change the status quo for the person who's diagnosed tomorrow, the person who's diagnosed a year from now, because it's not fair. how hard this is. And we can fix it. We're smart. We know how to do this. We know what needs to be done. Get it done. And that's what I think a lot of people don't realize. They think that we're going this slow, methodical way for some strategic reason. And it's not. It's because we don't have the funding and so as a community, do we really care about patient care and access or not? If you care about it, join us, support us and know that you are in vesting in an organization that partners with ASRM and other organizations to get this done in the most expeditious smartest, ethical way possible. And so that's what I would say. I would say that's the biggest kind of, I'm not one of the that's not the biggest but it's one of the biggest misconceptions that people have about resolve and advocacy in general. And they think it's like millions and millions of dollars that are being put into this and it's not it's not and so let's get this done. Get the start.


Griffin Jones  50:37

For those that aren't resolved professional members yet I see just every provider become a result professional member I see just every clinic get the clinic professional sponsorship, if you are a clinic network you better have a table at night of hope you better have a couple of tables at night hope if you're if you're in network you better be having doing a walk of hope if you're big clinic you better do be doing a walk vote which doesn't mean small clinics can I'm just putting this is the onus that I'm setting on people right now. And and and for those of you that are in any, any states, but especially the ones that were mentioned tonight, especially those ones, you better be at advocacy day too. So Barb Collura, President and CEO of resolve the national infertility Association. Thank you so much for coming back on inside reproductive health.


Barbara Collura  51:28

Thank you Griff. This has been a pleasure.


Sponsor  51:31

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

188 Comparing Compensation Models for Fertility Doctors with TJ Farnsworth


On this episode of Inside Reproductive Health, Griffin delves into the pros and cons of compensation models for fertility physicians in conversation with the CEO of Inception Fertility, TJ Farnsworth. 

Here are just a few key points to pique your interest:

  1. Different performance camps and metrics: In the realm of variable compensation, TJ highlights the various performance camps and metrics that can be used. 

  2. Two main compensation sides: TJ explores the two primary sides of compensation for fertility physicians, namely guaranteed income and variable compensation.

  3. Challenges with KPI-based compensation: TJ shares the drawbacks and pitfalls of tying compensation to KPIs.

  4. Simplicity and variable comp: TJ emphasizes the benefits of keeping compensation simple and honestly shares the mistakes made by Inception Fertility with KPI-based compensation. 

  5. Importance of physician ownership and other roles: TJ sheds light on the significance of physician ownership in calibrating incentives within the practice.


TJ Farnsworth’s LinkedIn
Inception Fertility

Transcript

TJ Farnsworth  00:00

So when we step in, we're, you know, becoming a partner with these doctors and I'm a big believer in the concept if it's not broken, don't go fix it just for the sake of changing and and so if it's working for them, then great and a lot of practices, you know, there's like there's different providers who did that are in different phases of life and have different different goals.


Griffin Jones  00:24

Let's get you paid a senior REI wrote in with this question, one of your peers wrote in with this question asking me to interview a CEO on this topic, and I do what you say so you the listening audience, when you want to know something deeper about a particular subject matter, let me know i'll try to find someone who will speak on it. And I'll grow them with a bunch of questions. This topic had to do with the pros and cons of different compensation models for fertility physicians. So I brought on a CEO I brought back TJ Farnsworth, you know him as the CEO of Inception Fertility. And because he's been on Inside Reproductive Health, many times TJ talks about the two main sides of compensation, guaranteed income and variable compensation within variable compensation, you have it tied to individual performance tied to practice performance within those different performance cam. So you have different figures to which you can tie those performance metrics. So which I mean to say you can tie them to KPIs like retrievals transfers, or you can tie them to a percentage of collections. TJ talks about the problems with tying them to KPIs such as who actually performed the surgery was the doctor of record is the EMR reliable, did the person checking in the person check them in with one doctor but was actually a different doctor of record is the accounting system getting the right information, TJ prefers to keep it simple. He talks about some of the mistakes that Inception fertility made in doing KPI based compensation, and why he likes variable comp as a percentage of collections. He also talks about what that variable comp doesn't sell for and why physician ownership is so important in calibrating the incentives. That's physician ownership in the practice. We talked about profit sharing, we talked about when it does make sense to have guaranteed income only and we talk about the division of labor outside of productivity roles. When you have an administrative role a medical director role I pressed TJ a little bit when we were talking about the incentives of five to seven Doctor practices, I seem to think they're harder to align than he does not totally sure I got on his page about that question, but TJ really did thoroughly answered that senior Doc's question. And that was the whole origin of this topic. You might have other thoughts on compensation, you might point out questions I didn't ask. So email me them. Tell me what they are. Give me more topics and questions so we can continue to build valuable content, Mr. Farnsworth, welcome back yet again, to Inside Reproductive Health, TJ. 


TJ Farnsworth  02:47

thanks for having me. It's always fun to be on here with you. You seem like this guy. And you're the only guy in the fertility industry whose hair I'm jealous of. 


Griffin Jones  02:53

Oh, well, right now is looking pretty similar. You know, the vast majority of people listen to the audio, they don't watch it on YouTube. But right now, but both TJ and my hair doing what it wants. But I think this is probably the fourth or fifth time that you've been on the show I always enjoy having you on. And I like the fact that you came on to talk about a topic that an audience member asked for. So to give the audience context, this was a senior Rei who wanted to know about compensation models. Now this person has exited their practice, I think, is practicing again, as an employee somewhere. So perhaps this is why this person asked, but they asked would you bring a CEO on to talk about the pros and cons of different compensation models? And and I said, I know a guy. And so I think the people like you TJ deserve credit. Because some people would say, Oh, I don't I don't know I don't want to say the wrong thing. It's like the people are asking for this. Come on, try to be generous with some darn information. 


TJ Farnsworth  03:10

And so there's not a right or wrong thing, right so it's it's there's there's there's 100 different ways to skin this and I feel certain that there's a there's there's only one truth to this. There's there's not really there's no right or wrong answer to this question. There's just different ones. 


Griffin Jones  04:16

So let's try to lay out all of the ways that one can skin this cat, like give us just an intro to the different compensation models that exist and then we'll start to explore them. 


TJ Farnsworth  04:28

Yeah, so I think I think all compensation models have one of one or more of a few components. One of which is potentially some type of a guaranteed income, whether it be in the form of base salary, or guarantee on on variable comp, some type of a variable comp program tied to a provider's individual personal performance, then potentially some type of variable comp program that's tied to a practice performance, which could include or be an addition to an ownership model that includes profit distributions. And so I think those are the there are various different ways to do multiple do each one of those components. And some, some called models will include all of them. And some will, would will include, you know, just just certain specific components of it. 


Griffin Jones  05:25

Is it rare nowadays to see any model that doesn't have any variable comp, or is there still, some of that may be in the academic sphere? 


TJ Farnsworth  05:33

Probably in the academic sphere, you know, we have, we're a little bit unique in that we do operate an academic fertility clinic, and in those in those in those we do have variable contractors in place. But so we think the majority of them are going to have some type of variable cost, because even in major hospital systems, and academic centers outside of fertility, you know, that they're, they're measuring productivity of physicians, whether it be on an RVU basis, or collections basis, or some other way. So I would be willing to bet that, that almost everyone has some type of a variable compensation flavor to it in some way. And, and you know, but there are some models like that, in our operation, I'd be happy to talk about, you know, even specifics around how we do it, Inception, there's no, there's truly nothing that's secret here. And there, we have some we have some practices that may not have an individual productivity component to it. But they have a ownership structure that allows for profit sharing. So obviously, as the practice grows, that they allow for that, I think it's important that we also consider not only the quantitative aspects of things, but also the qualitative because what, what is quoted the right or wrong answer, as we were saying earlier, might be right for one practice, but the culture of another practice, a different model might work better. Usually, even within an exception, for example, we don't have one compensation model we use across the US and Canada, or we have, you know, what works in one market, but each individual practice has some of their own personality to it. And so it works for that practice, from that personality. And some of them have their some of their own, like, just practical differences in terms of the size and scale and, and you've got some of the larger practices where physicians are specializing. And, and, and so it just indicates a need for flexibility. But I think ultimately, those foundational variables in terms of how you're getting compensated are always part of the equation in America, no matter what, no matter which, which worked recipe, you're going to combine those with. 


Griffin Jones  07:37

Walk us through two different scenarios. And then because then I want to explain, and then I want to explore that qualitative difference between those, but walk us through two different scenarios of two different practices that have different compensation models. 


TJ Farnsworth  07:49

Two wide examples. So in certain scenarios, you have more what I'll refer to as eat what you treat models, where there is no fixed base compensation, it's all variable. So, you know, unlimited upside, unlimited downside kind of a structures to them. And, and those work in certain communities in certain environments, and in all cases, at least with us, 100% of cases with us, all of our physicians are either partners with us in the practices or on a pathway to partnership. So even if they're already partner, or they're, we're on our way to partnership, and so on and 100% of cases, at least for us, the everybody either does or will have some level of stake in the overall profitability of the business. So in that scenario, where it's an eat what you treat model, that eat what you treat concept would be tied to their own individual personal comp, productivity, and then the, obviously the ownership share, which would take into account the overall profitability of the whole enterprise. And then you we have models where, where there is some level of base compensation, I think this is a more common model, where you've got a more some level of base compensation either in the form of a, of a guaranteed minimum bonus, or in the form of a salary, and you got a individual personal productivity component on top of that. And then in addition to that, you know, either their, you know, the more you having or being or on their way to having a share in the overall ownership with the practice. So it gives them the base salary, which I think most most physicians, you know, at least starting out want, so they have some level of predictability around their income. And then you've got the variable compensation that ties to their own personal productivity. And then you have the ownership component that would tie to the overall profitability of the of the, of their practice. 


Griffin Jones  09:30

So let's talk a little bit about the qualitative that makes one model fit for one group and not another. What is it about practice that has that it's all eat what you treat, it's all variable with the unlimited upside and the unlimited downside, what makes it a good fit for them that wouldn't necessarily be a good fit for someone else? 


TJ Farnsworth  09:55

Yeah, so a lot of it is history. So a lot of it is just the sort of a culture that's built there. So when we step in, we're, you know, becoming a partner with these doctors, and I'm a big believer in the concept, if it's not broken, don't go fix it just mistake of changing. And so if it's working for them, then great and a lot of practices, you know, there's, there's different providers who did that are in different phases of life and have different goals, right. So any what you treat model allows that physician who's who's more interested in a certain lifestyle, to make less, but balance that with with more time for themselves and for family and time outside of the outside of work, while at the same time you generate EMR. So you with the physician who is in the phase of their life, where they want to, you know, you know, maximize their productivity and thereby maximize their income. And so I so allows for that diversity of things. I think, though, that is, we see that model less and less often. But certainly, it's a model, we use us in several different practices. And then, you know, the other side of things is you've got practices where I bet you think some more common model where you have, you know, 5, 6, 7, physicians, that that that you're all aligned, all sort of were recruited, and, and built a culture around sort of a similar level of productivity. And as similar lifestyle goals, you have there on that for a base with some type of an individual personal productivity, and then obviously, a substantial component tied to the overall profitability of the practice. And then I'll introduce a third one for you, we have a scenario where we have a very large practice with 20 Plus RBIs, that has no variable compensation tied to the individual doctors productivity. And so everyone makes the same terms of base, and then they have their ownership of the practice. And the reason that practice does that is that they've gotten so large, that there's that they're their is specializing happening, and so whether that's specializing in certain regions of a market, or specializing in certain aspects of clinical care, where, you know, there may be somebody who is, is clinically passionate about certain things, but that's higher than that, that doesn't, you know, doesn't generate as much from a revenue perspective, but it's really important to the practice to have that component. And it's really important as the group to maybe be in a certain region or geography. And they don't want to penalize somebody for pursuing that that goal. And so the idea being that everyone is contributing to the overall benefit, and, and so they, their variable costs, so to speak, comes from the overall profitability of the business. So rather than everyone rowing the boat in the direction of their own personal productivity, they're all rowing the boat in the direction of the overall profitability of the enterprise. 


Griffin Jones  12:44

So in that case, so the third example you use with no variable comp outside of the profit sharing, and that was a 20 plus doc group, does that model only work in a group that size or larger in your view? 


TJ Farnsworth  12:58

I think the the the, certainly it's got to be a big group in order for it to make sense. And part of the reason why that group does that is that as they expand into new markets, as they expand into new regions, there's not, if they had a scenario where where where a physician was, you know, half their compensation was based upon their personal productivity that none of the doctors would ever agree to go out there, if so at that new office, and start sort of new and so they developed this culture, where where, you know, whether it was expanding to new geography or somebody who is going to, you know, focus on fertility preservation, and it's early days, where there might not be as much business for that yet until that practice is built, it was overall important for them to be building those aspects of the business, whether it be geography or that aspect of clinical care. And knowing that they want they didn't want to penalize somebody for going in pioneering that new business line or that new office. And this they developed this model do that with. And so I do think that it's unique that you have, you have, that you need a practice that's got a certain level of scale, to get to a place where in the world that's that that's necessary, but they started with a variable compensation structure, they just they migrate that over time. 


Griffin Jones  12:58

Are all the salaries the same? Or does that vary depending on seniority? 


TJ Farnsworth  13:49

Nope, salaries are all the same. 


Griffin Jones  14:20

So then how does profit sharing work in a model like that? If so, I would direct listeners to a book called Great Game of Business, which started off in the manufacturing sphere, but lays out an interesting model for profit sharing and the way profit sharing works in the great game of business model is that people get bonused a percentage of their salary, so it's not, so profit sharing is different from the person that might be make everyone in a company shares in the profit, but it's the person that's agreed or making minimum wage gets a percentage of what they make and then the senior executives that are leading their divisions get a higher percentage because it's a percentage of their salary. And so what how does profit sharing work in a model where everybody has the same salary? 


TJ Farnsworth  15:10

Yeah, so I think we're, I'm using the term profit sharing really as a placeholder, because in different markets, there's different in different states, there's different rules, different laws around how you can how physicians can be owners at a practice. And so in most cases, our physicians are just owners. And so they are taking profit share by virtue of the fact that they own a percentage of the practice, if they own whatever that percentage might be, they own 10% of the practice and the practice, you know, generated $100 profit, they're getting $10. And so in certain, in certain areas, we are able to do that because of the regulatory structure in that market. So you just use contractual park profit shares, you can give voting rights and all those types of things that come with with traditional art. 


Griffin Jones  15:56

And so in that example, of 20 plus docs, not every doc has the same owns the same percentage of the companies that correct some own more?


TJ Farnsworth  16:04

 Some of the more senior doctors own a little bit more. But it's not that it's not as big of a disparity as you might think. And over time, their model is that generally speaking, as us as a rule is, in the event that we do have, what I would refer to as more senior partners with more ownership that you want to migrate them to an equal ownership model, creating multiple classes of ownership is really not good for the culture. From our perspective. 


Griffin Jones  16:29

Really, we're talking about owners distribution, in this case, I should clarify that the profit sharing outline and great game of business is for the entire company. So even if you have 1000 people, and it kicks in after a certain net profit, threshold, yeah. So you know, if it's under X percent net profit then nobody shares in that bonus, and it's phased so that people can make it up in different parts of the quarter. But the whole idea is that everybody in the company knows what the target is, and they're all going for that. Do, is there, are you familiar with that model? Do you use that model anywhere where everyone in the company or everyone in the practice can share in the profit after a certain amount? 


TJ Farnsworth  17:12

We have the practice wide bonus structures in place in various different markets. But we don't we don't have, you know, company wide profit sharing plans in the way in which you're referring to it that is common in some industries? 


Griffin Jones  17:25

Perhaps it's because of the regulation that you were hinting at. But I wonder sometimes why don't some practices just do profit sharing with their partner docs as opposed to actually making them part owners of the business? What would be the con to doing that? 


TJ Farnsworth  17:40

There really isn't any pro or con, there's some some scenarios and some of the areas where there's tax advantages. So I think that the probably the biggest driver is tax advantages to it. But But I think generally speaking, physicians from emotional reasons want actual ownership rather than profit share, even though we can design structured profit shares to look and behave exactly the same way as traditional equity does. And our preference usually is just to do traditional equity. It's simpler. It's usually more tax efficient. But but it's oftentimes dictated by the regulatory rules around, you know, the corporate practice of medicine or statewide referral laws that might exist in any given market. 


Griffin Jones  18:26

Have you come across any funky state laws off the top of your head that you can remember that, oh, it's harder in this state, or people have to look watch out for this in this state? 


TJ Farnsworth  18:36

No, I mean, there's certainly there's their states that are more complicated. But the reality is, is that the, you know, the joint venturing, 


Griffin Jones  18:45

Did those complicated states rhyme with Alafornia and Zoo York? Or, or is it not always the usual suspects? 


TJ Farnsworth  18:52

It's not always the usual suspects, you might be surprised. Those certainly are complicated states. But even the state of Texas, which you think of, as you know, your way into the free market is one of the more complicated states. So it's not not quite that quite as straightforward. But I will say that any and all of those markets and all those states there I mean that there have been structures in place and have been in place for a long time to accommodate for physician ownership. And just like any, any regulatory environment, there's there's some group of attorneys that have that have constructed a very aboveboard and transparent clean way of doing it, that generates them some fees. 


Griffin Jones  19:31

Tell us more about the difference between variable variable comp tied to individual performance versus when it's tied to practice performance. 


TJ Farnsworth  19:40

Yeah, so we don't see the what I'll call just sort of traditional comp that's tied to practice wide performance very often. We do have it in a couple cases in our clinics only because they existed before we were there. And we prefer that the we as a company, I think most of the are this way as well. I would prefer that the way in which you participate in, in practice wide performance and improvement is is through profitability, because that I'm a huge believer in aligned incentives. And so if, if my incentives are the exact same as yours, it helps build trust, it helps build confidence in the decisions that we're all making, we all sort of we all win and lose together, that's, that's really, it's got a lot of value. So that's the way we lean on the practice wide accom structure, a variable comp structure. On the personal comp structure, there really are, I think, you know, two main models, one of which is tying productivity bonus to certain KPIs, whether it be retrievals, or adding retrieval being the most common, the other model, which I think is what we prefer, and which is some something tied to a percentage of overall collections of a productivity from that individual physician, that way, you're not tying it to some sort of clinical activity, I think, certainly, the intent of the bonus per VOR concept was likely never to try and drive some type of, of a clinical behavior, because obviously, we trust all of our physicians to make the right clinical decisions, you know, that's, that's, that's their specialty. But, you know, obviously, to do certain number of VORs, you got to usually you have to get through so much diagnostics, and so many IUIs and there's sort of some some mix of all that in there. But I do think that as you're moving more and more towards more managed care coverage for services, whether it be progeny are kind body or traditional Aetna, United, otherwise, you as well, as you see it, generally speaking, a an environment where you've got some physicians that like doing more surgical cases, you've got some physicians who like doing more for Brentford or fertility preservation in their practice, whatever it is, you know, a variable comp is tied to just collections, you know, allows for, you know, there not to be any, any environment where you're, you know, you're encouraging one behavior or another. And that's where we are moving to as a company, I think a lot of people in the industry are. Doesn't mean is that that's not to say, we don't have several practices that still operate off of, you know, what I call a KPI based model where they're using, you know, VR is or IUIs, or transfers or some other metric or combination thereof. But it's, it gets complicated. And I, I'm, I'm a sales guy at heart, and I'm a big believer in people's compensation program program should follow the kiss strategy, you know, just keep it simple, and make it easy for everybody so that there's no unusual complicated math to be done at the end of the month or quarter. 


Griffin Jones  20:11

So I started my career in radio ad sales, it was my first job out of college, which for anybody that's not familiar with that, it's here's the phone book kid. It's 100% commission, there's no training, it's a, you're a 21 year old kid, great, go figure out a way to have this 57 year old business owner who's been doing great in business for 30 years, give our company money, surely also had someone at our company who had burned that person in the past and it was 100% commission, I learned a lot from that. But the Keep It Simple was, that's what worked from It's Okay, if you want to sell more of this, tell me what the commission on it is. And but it sounds like, you know, just percentage of collections is a little bit different for so in my case, it was if you got this much new direct business, it was this percentage, if you could sell this much of our new online revenue stream, this much of our event revenue stream different commissions, is there that within that the percentage of collections or just percentage of collections just tend to be flat, because otherwise you'd be back in that KPI model? 


TJ Farnsworth  23:43

It is the flat otherwise, you're really back to a KPI model. That's just not fixed dollars. Yeah, percentage of collections tend to be, you know, maybe there's a sliding scale involved. But you know, in terms of thresholds of dollars collections, but but it's still just all dollars, not, you know, I just think it's from our my perspective, it's, it's adding a level of complexity to the to the model that, you know, again, I'm all about aligned incentives and trust. And if you don't ask, if I have to get on a spreadsheet to show you, how a calculation is done and take you take 45 minutes an hour of your time every month or every quarter to make sure the numbers tie out like you think they should. Yeah, it's just it's it's more administrative headache, and the fastest way we can burn out and frustrate our clinicians, which obviously include our physicians and providers. of all kinds then is its administrative BS. And so we prefer not to add another piece of that to the table. 


Griffin Jones  24:41

Aligning incentives makes sense but what's complicated about what's that where does the administrative headache come from? It seems straightforward number of retrievals or number of transfers or whatever, what complicates it? 


TJ Farnsworth  24:41

Yeah. So you know, it's, you know, I, you know, who performed the retrieval versus who was the doctor of record, making sure you can pull that out of the EMR consistently and reliably you know, and accounting is doing that from from Nashville, and does that actually align with what happened in the practice? Because just because somebody, you know, just because somebody at the front desk, check them in for retrieval, under Dr. Smith, when Dr. Jones was the doctor of record, and has a economic impact to that physician, it's just it from a, it seems simpler than it is from an from a from a, from a practical application perspective. And it's not overly complicated, look we do it, but it's just simpler to go, you know, you had $100 and collections, you get this percentage of it. And it's it's black and white. 


Griffin Jones  25:35

So it doesn't that that makes sense why you'd be moving toward that as a company. But doesn't some of that appear in the in the collections, you know, that if it was the doctor of record versus the visiting doc, how, how was it more clearly attributed with collection?


TJ Farnsworth  25:50

Because on the claims data, when we know when you submit a claims information, it's it's much cleaner that way, versus pulling out the EMR has a lot of impact on who's just charting it and otherwise. And look, ultimately you're solving for the same thing, you know, a certain number of these KPIs all add up to a certain, you know, on a blended basis, all at a certain dollar amount, you're, you're solving for the same thing, it's just how you get to that solution.


Griffin Jones  26:16

You said something earlier, in the when we were talking where we were talking about the different models, the blend of guaranteed income and variable comp, and you've got some that are almost all guaranteed income, and then you got some there, all variable comp, and then you've got the blend. And you mentioned, you know, sometimes you'll have a 5, 6, 7 physician practice where they've got similar productivity, they've got similar lifestyle goals. And I was thinking TJ, I've been under the hood of a lot of five to seven Doctor practices, and they never are aligned on on productivity and lifestyle goals. There's always one or two workhorses, that are a little bit grumpy, that they're doing a lot more volume, or, or they just, you know, they'd like their partners to pick up the pace or, and that's where a lot of the things that you come into, like was it actually my patient was? Were they using my nurse, etc? Come into to play? And so how do you align a group like that?


TJ Farnsworth  27:20

Yeah, I think that goes to not having the base comp be, you know, all that substantial from a from a I mean, it's obviously an important component, certainly, as a physician starting out, you know, they're fresh out of fellowship, that that's a more important component, the long term, you know, the variable and ownership components, I think are, you know, are always going to better align everyone's incentives. And not just, you know, I, you know, when I say better aligned incentives, I'm not just talking about Inception and the physician, I'm talking about physician and physician, a lot of times physicians are concerned about how does, how does this affect my relationship with inception, and who's got what incentive, and a lot of times, to your point, it's not us, they have to worry about, it's amongst the doctors, and I think that's mostly, it's mostly acute when you've got some generational differences, where you have some physicians that maybe are in the middle of their career that that, that kids are gone. And then they got some younger physicians that maybe have young children, and that want to be there for certain things. And I've got a seven year old and a nine year old, and certainly, it pains me sometimes when I'm on the road traveling, and there's a school play, and I understand the desire to be there for those things. And, and so it's always a balance, and, and it's never a perfect world, but I think you're trying to get to a place where you've got as much aligned incentives as possible. So that, so that, you know, the physician who is, you know, interested in a different lifestyle than another, you know, but they're both equally interested in overall profitability, the practice, you know, maybe one person is able to do one component of the business, maybe somebody is able to do cover the lab more often and do more retrievals earlier in the morning, so they could be done later in the day to look and be a little bit more of a division of labor that that occurs, so that I, you know, I could take some workload off you, or you can accommodate some component of my career, that alignment to the incentive allows for that. And then for the guy who wants to or gal who wants to just, you know, I mean, work seven days a week, you know, 12 hour days, you know, that, you know, having a component that allows for you're rewarded for that make sense. And, and so, we try and have a combination structure that allows for there to be as little animosity as possible, developed from those varying different places. And but I will also say that, you know, aside from those generational differences, most of our practices tend to recruit like minded physicians, so yeah, whether you know, whether it'd be somebody who's whose kids are now gone. They're, they're empathetic to the physician who's got up third grader, that hey, I was that place I was that place one time in my career. And, and people were empathetic with me. And and I'm going to I'm going to help them at this stage in their career. And so those are those are qual, those qualitative differences that exist from, you know, I call practice personality perspective that I think are important when you're evaluating whatever, comp structures,


Griffin Jones  30:22

I see the generational side go both ways, sometimes. On one side, you might have someone whose kids are out of the house, and they they're ready to work because it's that,  golf or their spouse, and they, they just, they'll go to work and, and sometimes you'll have physicians with younger kids that need more time with the family. But I also I see a lot of young ducks who, they they go home, they kiss their kids Good night, and then they go right back to work, you know that? 


TJ Farnsworth  30:49

That's absolutely right. That was just meant as one example. 


Griffin Jones  30:52

And then there's a lot of Doc's closer, who are a little bit older than say, Man, you are, you're traveling the whole globe, you're going everywhere. 


TJ Farnsworth  30:59

Yeah, and I want to I wanna play more golf or whatever. Yeah, totally. There's no question that goes both ways. And I don't mean to say that the one is, whose kids are gone, or is always more productive. That's not the case at all, we absolutely have lots of young physicians who are just absolutely be focused on the greater degree of productivity. It's really just, there's not one or one right or wrong answer, right? Like, I completely understand why I mean, I'm a workaholic with a seven and a nine year old. So I totally understand that that person is sacrificing something and, and there should be reward at the end of that for that. And I totally also understand, my wife just retired earlier this year, after 20 years. And because she wanted, both was want her to have more time with the kids. So yeah, neither one of those is right or wrong. So


Griffin Jones  31:44

You brought up something else that begged another question about the division of labor of things that are outside of productivity, different administrative roles, if someone is part of you know, they they are part of a committee that makes marketing decisions?


TJ Farnsworth  32:01

If someone could take more call. I mean, there's all kinds of things, 


Griffin Jones  32:05

But what about those types of things that the practice needs to run? But maybe they have an administrative role? Maybe they're the medical director, maybe they're running a fellowship program, if you've if you've added that on, but they're not aligned with productivity? How do you align incentives? Or how do you account for that? Because they're, they're still contributing to the overall group, but they're not as their collections aren't as high.


TJ Farnsworth  32:29

And that's why the ownership vote component is so important, right? That that aligns everyone perfectly, because, you know, and then all of those other things that you're doing that healthy overall practice on a more global basis, you see that benefit yourself and the rest of the group see that sees that benefit of that work you're doing and is appreciative of that?


Griffin Jones  32:49

Does it still tie it because if we're all sharing at the at the the overall level, but you're able to see more, folks, because you're getting a higher and you're getting a higher percentage of collections, but I have to do this? It still seems like Person A is winning out?


TJ Farnsworth  33:05

Yeah, I mean, look, there's not I mean, you know, perfect scenario, right? There's no one perfect answer. And so you have to look at individual situation and say, Okay, maybe there's something you need to change here. You know, there's, there's all these sort of guidelines and rules, and they're all made to be broken, so that so that you can make the right structure for that one group. But some groups might say to themselves, hey, this doctor is going to do make it, I mean, going back to that practice, I mentioned that it has no individual variable costs, because at this individual doctor is going to do more of this one thing, that you may generate less individual collections, but it helps the overall practice. And that's why there's certainly a more common structure in our in our world where, where a small component of things or smaller component of things is tied to very their individual variable, personal productivity. But still, a lot of their comp is tied to the overall profitability of the enterprise, because obviously, their individual personal productivity, and everyone's individual personal productivity impacts the overall productivity of the practice, too. So all this is tied together. It's, it's as you pull one lever up and down, it impacts the other levers.


Griffin Jones  34:07

How does overhead play into all of this? 


TJ Farnsworth  34:11

Well, I think that's what that's why the ownership component is so important, because when when physicians have ownership there, all of a sudden, as just as interested in all we are, and being efficient with our use of overhead costs, and why I say efficient, I don't mean, you know, as low cost as possible. That's, I know, there certainly are operators in the market, that sort of focus on low cost. And there's certainly a market segment for that, and a component for that, and that's fantastic. They're meeting the needs of patients in that segment. That's not our model. So, you know, we are, you know, but but at the same time, you're always trying to be cognizant of not spending more than you need to because all of that ultimately has to be passed on to the patient in terms of higher cost of services. And so, you know, or lower product or lower profitability for the for the owners and so, so I think It's it's in, it's important that it helps to align the incentives. Okay, we're gonna go expand and build a new satellite office and invest in that. And that's going to reduce our profitability for a little while, but at the same time, it's going to long term grow our profitability, and it starts to get everyone thinking, longer term time horizon versus just what are my collections next quarter. And, and it really gets us more aligned in terms of what the strategic goals are, for that practice.


Griffin Jones  35:30

So it the two balance each other out their collections gets them thinking about what they're doing in the present, but the ownership accounts for all of the things that that collections might not account for, or you simply sometimes need to counterbalance both things like if I have, like, if I had an employee satisfaction score only is it well, that could come at the cost of just letting my employees do whatever the heck they want, and not having any accountability to the business or not having any accountability to the customers. So you might want two or three and this sounds like two you have ownership and you have individual bonuses on or individual comps somewhat tied to collections. So how do these so So then how do you make some of these decisions involving partners is that some decisions are going to be made at the executive level? Some you involve them more? How does that work? If someone says, Well, I think this is wasteful, I think we're wasting money on this supply that we could get from a cheaper place. How do you make those kinds of decisions?


TJ Farnsworth  36:38

Yeah, I think it depends on the individual decision. I mean, clinical decisions, we obviously rely entirely on the physicians, when it comes to business things, some of which we make on individual practice basis, we discuss it as a group and make it a decision together, some of which has to be made, you know, on a on an enterprise basis, and we wouldn't choose different accounting systems for different practices, for example, that just doesn't make practical sense. Yeah, we uniform, you know, health benefits, right? We buy. Inception is 2600 employees now in the US and Canada. And we buy health as health insurance for everybody at once, right? So we are not we're not we're not sitting down with practice individually going here, our options between United and Cigna and that decision is being made globally. But that that alignment of incentives builds the trust to know that we're making the right decision because it impacts us all equally, I'm not going to, you know, we're not going to we're not going to make a short term decision, then have terrible employee benefits that ends employee ends up in the end bad employee satisfaction, so that we have high turnover, just to just to benefit the bottom line. But we're also not going to go out and you know, purposely pick the highest benefit choice for no reason.


Griffin Jones  37:53

I thought of another question that I want to make sure I asked you before we're done. But to clarify, we're going back to the the the way that collections is tied to comp that it's not collections minus overhead is it's 


TJ Farnsworth  38:08

No, no,no, off the top. Otherwise, everyone starts to wonder what that overhead means. I mean, the the collections minus overhead is their ownership component. That's that is. That's, that's that piece of it.


Griffin Jones  38:21

Tell us about the difference in equity at the practice level equity in the parent company level, and how each of those can work.


TJ Farnsworth  38:31

Yeah, I mean, it can be the equity and the practice level, you know, the, the, the physicians, and everyone that participates in that can see, hey, I do X, and it impacts y. Right. I mean, you know, ownership and the inception level. Yeah, it's, it's, it's, you know, any individual activity is diluted by the same by the scale of the business. Right. So it's, it's hard to see how your individual participation impacts the overall whole. In addition, the our practices all make profit distributions on a monthly or quarterly basis. Inception doesn't do that Inception invests reinvests its earnings in in growth. And and so the only time that physicians would participate in the profitability of their or their or their ownership at the inception level, is it a liquidity event, which obviously has got a lot of benefits to those physicians, but you know, it's there's not like the new one is not as a right or wrong, it's just they're just have different different positives and negatives versus, you know, the monthly or quarterly profit distributions that happen at the practice level, that obviously impact the lifestyle of that physician in terms of their ability to support themselves and their family.


Griffin Jones  39:44

Can that misalign incentives between practices though, if people are bought if they if they share in the profit of the at the practice level, but not at the parent company level that that makes one practice Want to go in one direction or another in a different?


TJ Farnsworth  40:03

We don't see that? No, I mean, we have, we have both. So we have scenarios where physicians are ownership at the at the parent company level. And but in all cases, physicians are either owners at the practice level or are on their way to be owners at the practice level, because that's where they can see the impact of the profit distributions. And obviously, that profitability, the local level impacts the profitability of the parent company level. So that's where the alignment of incentives happens between the practices and the parent. 


Griffin Jones  40:35

I've asked you quite a lot about different schema that can be used for compensation. What haven't I asked you? Actually, before I asked you that question I want. Are there any examples that you think of that you're comfortable sharing of? Hey, that was a mistake we made earlier on that we we did something and it it misaligned what we wanted, but is there any example that you'd share?


TJ Farnsworth  41:00

Yeah, I think that, absolutely. I think I think, I don't know about you or your listeners, but I Oh, we learn a whole lot more from the things I do wrong than from the things I do right.  Because it hurts. Yeah. And yeah, I think, you know, going back to an earlier comment I made, you know, we have certainly our past created compensation models and structures that we thought drove alignment of our interests, through the through compensate through complicated variable compensation structures, you know, you know, complicated sliding scales of percentages, complicated thresholds, of hurdles, you know, separating, you know, revenue associated with certain services, from others and complicated KPI models, and it always breeds a certain level of like, or somebody, you know, are you are you playing with the numbers are you gaming in the system, you know, are you and it it, it creates some a level of mental gymnastics that, that is brain damage for both Inception and then also for our physician partners, that it's just, it was unnecessary, and it was a it was, and we, and we created a scenario one time, where, you know, we we segmented once the ownership of the business into the physicians, and inception. And those physicians, you know, all a shared in the profitability of the business after the compensation of the physicians using this as an example, the second example of things we did wrong, and what it ended up doing was an unintended consequences. It made those physicians, you know, an incentivized to hire new doctors, because those new doctors would only impact their side of the profitability. And that just made no sense. And that's why, you know, we've gotten to a place where we're real big on, you know, we there's no, there's no, there's no classes of ownership, while certain state states might say we've got to, we've got to create, you know, create that call them super separate things, because one's a physician and one's not, you know, we don't get money, we, you know, Inception doesn't get dollar one, and the doctors get dollar two, we all share in dollar one. And we all share in it the same exact way. And it just creates a scenario where there's a level of transparency, and a level of trust that's developed from that, that I think, you know, we we, in certain instances, frankly, screwed up at various times in the past, you know, that in code in combination with screwing up the variable comp structure through various overly complicated models that I think, again, when it gets so complicated that everyone's got to get an Excel spreadsheet out to understand it, it just creates a scenario where you just naturally breed mistrust. And that's not what we want.


Griffin Jones  43:43

Well you've certainly answered the original question from the doctor who wanted us to cover this topic. I'm gonna let you conclude.  How should we conclude about compensation models for fertility doctors?


TJ Farnsworth  43:55

You know, I would tell you that I think it's important for everybody to realize there's not one right or wrong answer, that the individual dynamics of a specific practice might drive the there might be really good reasons why something's been done that way. And And certainly, if you got a physician who  is evaluating a job, I think, oftentimes asking the why question like, why do you do it this way? Like, you know, and why have I take this job over here? Is the structure different than the job over here? I think it's really important, because, you know, I think, in most cases, I think there'll be a really good explanation for why and it'll make sense and it'll, it'll give you the sense of confidence in making that decision. And I think, you know, whether it be like the geography or the size of the practice or the individual culture of that individual practice, you know, it's really important to find the right answer for that right practice. Not, you know, hey, there is one right answer for all practices.


Griffin Jones  44:52

TJ Farnsworth, it's always a pleasure having you back on. I look forward to having you again. Thank you for coming. 


TJ Farnsworth  44:55

Thanks, Griffin.


Sponsor  44:55

You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic Thank you for listening to Inside Reproductive Health.

187 How Fertility Doctors Start Tech Startups with Dr. Brian Levine


With Dr. Levine we learn:

  • How he leveraged his connections to unite with his fellow CCRM New York co-founders

  • The “Aston Martin” amount of money invested to validate the business concept (and how that number was chosen)

  • The first people hired (and why)

  • His criteria for establishing new partnerships with other firms and businesses

  • How he gets founders and executives of elder care companies to come knocking on his door (and what the heck elder care can teach us about reproductive health)

  • And more…


Company Name: Nodal
Dr. Brian Levine’s Social Media: LinkedIn, Instagram, TikTok

Transcript

Dr. Brian Levine  00:00

I started actually seeing that my participation, this was actually could be construed as me being complicit in the current system, I actually felt super responsible for trying to fix it. And because I saw what I think, is a very tangible, easy to use solution that helps reduce the cost and make it more accessible for people. I felt like that is completely in line with the oath that I took when I graduated medical school, which is to do no harm.


Griffin Jones  00:34

Finally, starting that idea that you have for a tech startup, almost every fertility doctor seems to have one of these ideas. And for some of you, it is bugging you crawling around in your head. So I decided to bring on someone that is going through this journey. Right now, you might know Dr. Brian Levine, he's been on the show before. He's the founder of CCRM, New York. So we talk about that establishing an established business, Dr. Levine has had his take on building something in New York. But CCRM is an established company versus what it's like to be the founder and the founder of something that isn't a practice network, but as a tech company that serves the verticals of which his practice sometimes overlaps. We talk about the concept for the problem in this case having to do with surrogacy, but I'm more interested in Dr. Levine's rules for how he articulates the problem and the solution. We talked about the connections that Dr. Levine leveraged to both explore the concept and unite with his co founders. We talk about the Aston Martin amount of money that the three of them put in to validate the concept and how they chose that number. We talked about the first people they hired and why there are rules for structuring market research talk about Dr. Levine's strategy for approaching a two sided marketplace. have Dr. Levine tell us about what he's doing with the money he's raised, what he plans to raise next, and who he's looking at selecting to partner with him, or at least what criteria he wants for those individuals or firms. And we talk about how Dr. Levine has done deep investigation into different verticals. To understand how those lessons can be applied in the reproductive health space. He shares how he gets execs and founders of elder care companies to talk with him and what the heck, eldercare could possibly teach us in reproductive health. If you're a fertility doctor or someone else in the reproductive health space considering starting a tech startup, I hope you enjoy this conversation with Dr. Brian Levine. Dr. Levine, Brian, welcome back to Inside reproductive health.


Dr. Brian Levine  02:34

Thank you so much, Griffin, I'm super excited to be back again.


Griffin Jones  02:36

The first time we spoke it was about starting a practice group within a network setting. You started the de novo CCRM in New York, and we spent the that episode talking about running that operation starting that operation. Today we're going to talk about what it's like when a physician does something even more entrepreneurial, perhaps in a related space. And so let's talk first about maybe some of the differences. So you have started a program for that's in the surrogacy space that in many ways seeks to disrupt the surrogacy space, the first your venture with CCRM, you, you were operating a system that was established, certainly with your own flair, but you weren't the first CCRM practice. And you deliberately went with a group that had an established system. So how did those two things differ? And maybe even before we dig into that, let's let's just dig it into what gave you the itch to start something new in the marketplace? 


Dr. Brian Levine  03:50

Sure. So,you know, as we talked about last time, the approach that I took back in 2015 was not the standard, and it was not the common approach. Typically, fellows were graduating from their fellowships, and they were moving on to going on to an established program, typically not academics and a couple of us into private practice. For me, I felt like there was a need to kind of change the model. And CRM afforded me the opportunity to have an incredibly tech driven approach, where I thought we can infuse some high touch Customer Care. And I think that's what we've been doing now for the last seven years since we opened the doors here. And it's amazing to think that it's been seven years since we opened the doors. As surrogacy was legalized in New York State, which happened in February of 2021. I was super excited. I kid you not I was like the single most excited person ever. Because before that, we had to ship all the embryos out for people who are doing gestational surrogacy. And then what happened was after about five months of doing this in New York, I realized very quickly that my patients were being preyed upon. And what I noticed was that the model of so Argosy in the United States, was not just unique the experience that I was having, it was a common experience across the board, which is that it was becoming price prohibitive and time prohibitive. And so I had no desire to start a business, I had no desire to be entrepreneurial, again, like the CCRM is very good and life and the practice is pretty amazing. But this problem, I couldn't unsee it. And I couldn't fix it. And because of that, it's why I took that step to kind of build something different and to fix something.


Griffin Jones  05:29

Maybe I'm making an erroneous assumption. But I've got to believe that you've seen many problems that you feel like you could contribute to fixing in some way that are a pain in the neck for your patients, that there's some solution that could be better if you pursued it, I got to believe that you could go down a list in your head of those things. And that more than one thing has irked you in the in the eight years that you've been running a practice. Why this one?


Dr. Brian Levine  05:58

So all the other issues that I've seen in reproductive health and the delivery of fertility care, are exciting and frustrating, and all the things in between that get, you know, under the skin of an entrepreneur trying to fix something. But when I started seeing the supply and demand economics as what was taking hold of servicing, and I started actually seeing that my participation, this was actually could be construed as me being complicit in the current system, I actually felt super responsible for trying to fix it. And because I saw what I think, is a very tangible, easy to use solution that helps reduce the cost and make it more accessible for people. I felt like that is completely in line with the oath that I took when I graduated medical school, which is to do no harm. And so to answer your question, why did I jump in with two feet and my wallet into trying to fix this problem? Because I felt like if I didn't fix it, I was part of the problem.


Griffin Jones  06:56

So it starts off with a feeling of responsibility that you part of the problem that you're not fixing it you can visualize this solution, how did you begin to explore it.


Dr. Brian Levine  07:05

So started, like most entrepreneurial activities happen, which is with a formative phone call, I called my friend who had an incubator in Florida. And I said to him, Hey, if you find any businesses in the services space, let me know, I'm happy to invest. I'm happy put some money behind because I think it's a broken system. And he then pushed me a little bit further. And he said, Well, what's the solution? And I said, Well, look, if a life insurance or health insurance company can underwrite risk on me, in a matter of minutes to figure out how I'm going to live for 20 years of premium payments. I think we could underwrite someone's uterus for 10 months using very similar databases. And that approach is what I said to him. And then he said, the most powerful thing ever. If you can articulate the problem, and you can articulate the solution, it's your responsibility to actually move forward and try to do it. So I did.


Griffin Jones  07:54

So how did you articulate that solution?


Dr. Brian Levine  07:57

What was it about the problem that you were seeing that made you say, we can do something similar to how insurance companies are underwriting their customers? So I think today, right now, everyone talks about the entire system being supply constrained, everyone says there's a shortage of surrogates that a shortage of capable individuals who are able to actually carry a pregnancy to full term. And because there's a shortage of supply, the costs have gone like through the roof. So I felt like if you just got more supply out there, the cost would have to go down. Right, if you make it more affordable, more accessible, while the access can be about supply, and that would dictate the economics and make it more affordable. It was a feed forward approach, fix the supply, you'll reduce the cost, reduce the cost, you'll improve the times and the wait times. And truthfully, as a doctor who was on the other side of it, he was not aware of how crooked the system had gone. I mean, if it had gone, not even crooked, I'd say it wasn't broken, because it's untracked. And what was happening was that, in reality, surrogacy services in the United States were being served to really only the 1% of 1%, who could ever afford that. And that's not why I went to medicine. That's not why I wanted to healthcare, and go into healthcare just to serve a very small population. I became a doctor because I want to help people in general. And so to me, I felt like if I could figure out how to supply the system with better surrogates, and really do what I call top of the funnel, then I thought that if we can do top of the funnel well, and we shorten the funnel, well, then ultimately we'll be able to make a meaningful outcome at the end. Was it really one phone call that one for that one phone call? It wasn't multiple phone calls and deliberating and looking at things from different angles? No, because actually got even it got even weirder than that. So when I said to my friend, John, who's the guy who I had that phone call with, and I said to him, this is the problem. This is the solution. And he says to me, Look, if you can articulate it We need to fix it. He then said to me, Hey, Brian, let's start the company. I said, I don't know, how did you do that? And he goes a simple you need money? And how much money do you think you need? I said, I don't know. He's like, I'll tell you right now, you'd have a million dollars. So why don't you me and some other guy put our money together. And let's do this on Monday. And this punk was on a Saturday. And with minimal approval for my wife, before I knew what I was wiring him effectively the cost of an Aston Martin, to start this company within 48 hours.


Griffin Jones  10:27

What made John such a confidant that one he was your main phone call and to that when he did propose going into business with you that you jumped on it?


Dr. Brian Levine  10:39

So John has a serie is a serial entrepreneur. And he had incubate a number of companies in the past. And he's a tech guy who I trusted. I've known him for a number of years. And, you know, like most things this world is, you need to have a friend that you trust, and there needs to be an element of excitement. And the trust and excitement that was there was the right combination. And I think the right prescription for what I needed to get me out of my comfort zone.


Griffin Jones  11:02

So this can accelerate things for those that might be considering venture if you have people that you trust. And if you don't have people that you trust with subject matter expertise in business development and venture capital in tech, then it makes sense for people to start networking and start making these relationships beyond simply their medical colleagues, because they might need the connections to move a little bit faster. And this could have been John, for you. It sounds like it was I want to get to the jumping in with the money. But how did he make you articulate the problem to him? And why was that sufficient enough for him. So this is your space. He's in a different space, tech finance. And somehow you were able to articulate the problem clearly enough to him that it was worth him wanting to do to be part of and put in some of his own money. What was he looking for?


Dr. Brian Levine  12:05

I think he was looking for a problem that was easy to understand. And I think when you start talking to people about health disparities, which is probably something we don't talk about enough in the fertility world, right. I mean, right now, it's June, and it's Pride Month. And we don't talk about the rates of infertility and LGBTQ plus population, because we don't know them. And right, we don't understand a lot about the health disparities. But when you start saying to someone, there's a real system, that's not fair. And you tell someone that it's really designed to help a very small subset of patients. And as a clinician, it frustrates me. And he started telling him about all the broken promises, and I tell him about all the tears that I see in my office. And the tears and the broken promises, and the frustrations were all related to the cost of surrogacy to the time associated with surrogacy. And I told him that I think there's a way we can fix this with tech. He's like, amen. He's like, You just gave me an elevator pitch without even realizing it. I'm in. Now, I do have to tell you, there was more than one phone call, actually called one of my oldest friends from Cornell, where I went for undergrad. And I said to him, Hey, Scott, tell me why I shouldn't start a company. And he's like, What are you talking about? I was like, here's my concept. Tell me why I shouldn't do this. And what he said to me was, Brian, you should do this. And I'll write your first check. And he was my first investor.


Griffin Jones  13:32

So how did John come up with and then offensively three of you come up with the magic number of half a million dollars?


Dr. Brian Levine  13:42

Completely pulled out of the air. So completely, he said to me, luck, I've incubated, you know,


Griffin Jones  13:49

What I think the three of us can scrape together without having to get too much buy in from our wives.


Dr. Brian Levine  13:55

Correct. He's like, I think you made a ton of companies. And $500,000 should give you enough runway to figure out if this is a viable opportunity or not. And that should give you enough runway to hire two or three employees to really do the market research you need to do and to put the infrastructure in place and to build a brand. And he goes and that's the right number. And to be honest, he was completely right. Right. That was exactly the right number spot on was, you know, you could probably start a company for much less. But we want to be effective and efficient and have first mover advantage, which we have today.


Griffin Jones  14:26

So you put in half a million dollars together. What did you do with the first half million?


Dr. Brian Levine  14:33

We hired two people. And the first two people we hired our Chief of Staff, Talia who's still with us today and Odle. And then we hired VP of engineering. And the first guy who is with us was amazing. And in fact, the entrepreneurial bug bit him so hard, that after being with us for 10 months, he started his own company. And so he actually left nodal to go start his own company, but we're able to hire an Unbelievable VP of engineering to come right in behind him. We've been amazing with us today. And ironically, since childhood best friend. 


Griffin Jones  15:07

The VP of engineering makes sense because you're building a tech platform and you want more tech brain in the organization early on, Chief of Staff seems could see mod for an organization that had two people why Chief of Staff? 


Dr. Brian Levine  15:21

Great question. So I think a Chief of Staff is an underappreciated swiss army knife. And knowing that I need to spend my time and days running both a fertility clinic and running a company, ie to have someone who has a skill set that can be multifaceted. And so when we look for this, for this person, this chief of staff who was our first hire, we wanted to make sure that he or she ultimately, as a she had all the right tools and resources at their fingertips to help start and grow and scale a company. And so it's actually the beautiful, most perfect title for someone who does everything from, you know, the initial scheduling to the accounting to the design, to the hiring, the marketing to hiring the general counsel. And to this day, because this person was intimately involved in every single hire is the appropriate title for them today, still, to this point to be a chief of staff.


Griffin Jones  16:15

It's a hard set of skills to find, because you're looking for someone who is as entrepreneurial enough to help build something from the ground up, but not so entrepreneurial, that they're the ones that are already doing it themselves. So how did you how did you select this person?


Dr. Brian Levine  16:35

So we went through the classic entrepreneurial workflow, which is you tried to find someone who had health experience in the past, who had the entrepreneurial bug within them, who was early enough in their career that they were willing to take, you know, a leap of faith, and most importantly, was a good fit for us. And we got so lucky through our network of friends of friends that we found Thalia, who's with us still to this day. And to be quite frank, I view Talia as the future leadership of this company as we grow this company continuously. And it's amazing to see that she's taken her entrepreneurial skills to help start really with us from zero and to build and to grow and to stack and to scale this company to what we are today.


Griffin Jones  17:16

So this initial funding, you hired two people, you're proving the concept, what did you do to prove the concept?


Dr. Brian Levine  17:22

So what we ended up doing was doing a ton of market research. And it was good old fashioned market research. So Talia and Kyle who started with us, the two of them started calling agencies. And they started asking questions, how does it work? As it how do we do this? They started calling fertility clinics, what do we do next? How do we get started. And they literally did market research from ground zero of what's it like to be a patient or intended parent to learn all about how the process goes. And then what we did was we did all of our research in a very structured way. And we organize our research answers, using spreadsheets and data sources and whatnot, to really help synthesize to make sure that we were asking the right question and that we were poised to answer that question appropriately. You see, what I've watched happen to all my friends and my friends of friends, who started companies where they haven't been successful, there seems to be a common denominator across the board. And it's called mission creep. mission creep is a very dangerous concept. It's almost a utopian concept where you think you're going to solve one problem. And then you realize you have these tools at your fingertips and you start branching out to solving everything. That's the jack of all trades, and masters of none. And as a 43 year old founder, I realized very much so that you need to be focused, need to have a focus that's on a specific goal on a specific mission, a specific approach. And that was the goal from the beginning. And so I want to make sure that our approach was data derived and was rooted in the research that we did, which it was,


Griffin Jones  18:58

What data were you sticking to and what little bells were trying to distract you?


Dr. Brian Levine  19:04

The data that we stuck to and we started asking people wait times, we started calling up agencies and saying, How long is it gonna take Alan's gonna take to go from hello to baby? And that was typically our number one question. And what you can see that we are started setting confidence intervals and you know, median time to start doing statistics on it. And then we started asking other intended parents, we started joining Facebook groups of support groups, how long is it taking you? How long are you waiting? And then we started realizing that there was actually a disparity between what people were quoted and what people actually were getting. And the little bell they were trying to distract us was everyone's like, don't focus on wait times, you know, focus on donor egg, focus on donor sperm or things like that. And what we kept saying to ourselves was focus on Saturday, see, focus on supply, focus on widening the funnel, focus on shortening the funnel, solve one problem at a time and that's what the job of a leader is. Right? The leaders do. Be the infectious optimist, which is what I've been doing my whole career as a fertility doctor, right, helping people understand there's possibility when they think they lost all hope and opportunity. And then also helping people understand the problem at hand and that the problem was is within grasp. And that's what I do every day at nodal right, I help the team understand that they are fixing a broken system. And then their hard work is going in directly to the efforts of helping people ultimately achieve their goal, which is either just start grow or complete their families, this obviously,


Griffin Jones  20:32

Isn't easy to do, because you have to be so receptive to such a small amount of feedback, do you know what I mean? You have to be maximally receptive to a minimal amount of feedback, and it's your job to vet what that is exactly, because you can't ignore everything part of what you're doing is proving concept and you need to understand what the market is telling you and then you need to assess product market fit and all the more so but you'll you'll get everyone's opinion in there, you'll get them prioritizing their own problems or or some other thing that they see in the marketplace. And and you're hearing things like oh, focus on donor egg and, and a few others, what arguments were they making to you? And how did you decide to tune them out, at least for now?


Dr. Brian Levine  21:20

So everyone was saying the same two things. And by the way, that can be VC companies. Or it could be friends or could be fellow investors, which is the TAM is too small. The industry is too small. You're fixing a niche. Why focus on a niche when you can focus on you know, blue ocean as a guide, you don't understand. The current system of surrogacy today in America only addresses 8% of men need 92% of the people that hope to use surrogacy as a way to grow or start or complete their family can not do so. And the reasons they say they cannot do those things are because it's cost prohibitive, time prohibitive, and emotionally expensive. So focus on the problem that we have, and as a company stay focused on that problem. And then of course, we can spin off other derivative companies with the same tools that we're building today. But focus on the problem at hand.


Griffin Jones  22:15

Jeff Bezos could have picked any number of categories to revolutionize ecommerce he started with books, you have your reasons for, for choosing surrogacy and ignoring the what are currently distractions, at least for the time being until you've established what it is that you're trying to build. So you've proven the concept, at least on the market need side from the market research at this time when you still just have two employees and that initial seed money that came from you all? Or did you have anything yet to assess product market fit? Did you have any kind of prototype? How did you build that?


Dr. Brian Levine  22:53

So we initially learned very quickly was that if we said to an agency, hey, if someone comes with their own surrogate, we give them a discount? They all said yes. And we said, hey, if someone comes to me with surrogate, will you help them get across the finish line? And they all said yes. And very quickly, we understood that we could be collaborative, and not just competitive to the current system. And understanding collaboration in the setting of competition is really important. And once we knew that, we had that there. The next question is, well, how do you do it? And the answer was a two sided marketplace. Right? The answer was letting service onboard themselves, letting them be able to build a profile for themselves. And because I believe in equality and transparency, I felt like you need to put the power back into the woman who's the surrogate. So by offering an opportunity for her to make the first move, Allah Bumble, or she picks intended parents that she wants to work with, instead of being assigned to an intended parent, we felt like was a great way to change the model upside down, and to offer them and also empower people to be more engaged on the platform.


Griffin Jones  24:03

It's hard with two sided marketplaces, because you need two sides. You need the Uber drivers and the Uber passengers you need the Airbnb guests and the Airbnb hosts, you decided in your two sided marketplace? Let's start with Sarah gets. And is the reason that you did did you perceive a greater shortage of surrogates or greater challenges in recruiting surrogates than intended parents and you feel that you felt like by giving them the opportunity to make the first move that you could make more headway on that side of the marketplace? 


Dr. Brian Levine  24:38

So we felt pretty quickly in our company's trajectory that it was important to give opportunity and agency to those women who are taking the greatest risk to their own family. By definition, a surrogate must be a mother and we know that these women who are unbelievable partners in helping to grow family and start families need to be shown that I think the brighter side of the transaction, they need to understand what's going on. And I think they need to understand that they are in control. And so the only way that made sense to me and again, this was our thought as a team of three at the time. But how do you give someone controls you let them make the first move? And that's what we did. And that's what we've done to this day was really letting them make the first move. 


Griffin Jones  25:28

Technically, what went into the first prototype? Or the first maybe if it was even pre prototype, but demo? 


Dr. Brian Levine  25:35

So the first, the first prototype was that could we build a platform where people could just onboard themselves? So that's pretty standard that you can build that out? The second part was, could we throw out a little marketing or a little test kitchen to see if we actually could attract potential people who'd be interested in becoming a surrogate, or learning more about surrogacy? What we learned very quickly with some very quick AV testing, that we were able to message and market to people the right way. Ultimately, the big marketing push happened six months later, but that was the initial AV testing was, could we build this? And could we build a marketplace?


Griffin Jones  26:11

How much time passed between initial seed funding of your 500k between the three co founders, and when you decided to raise additional money? It was approximately six months. Who did you go to first? And what did you develop in your, your pitch deck? How did you build that?


Dr. Brian Levine  26:30

So one of the rules was that the pitch deck had to be 10 slides or less. I realized that everyone, my role, I realized that everyone is busy, and they have a lot of time. And if we cannot articulate the problem and the solution in 10 slides, and we have no right raising money, we have no way starting a company. Because if we couldn't be succinct, we couldn't be effective. So the goal was to build a 10 deck slide, which we did. And I went out to friends and family. And these are the people who've been rooting for me since I started with CCRM, New York and the people that I'm rooting for me, since college and grad school and med school and residency and fellowship. And I went up to my friends and family and I said, Hey, guys, this is crazy. But I can't unsee this problem. And I'd love to have you on this journey with me. And initially, we thought we'd raise just $1.5 million. That's what we thought we needed. And I was gonna do it all BSafe, which is financial structure that comes from the Y Combinator, what we learned very quickly was that doing this via safes was a very easy way to do the transactions. And the challenge of getting 1.5 million was actually not that big of a challenge. In fact, they sold the 1.5 million in three days. What I learned very quickly was that we were very good at fundraising because everyone knew someone wanted to use surrogacy as a solution. But no one actually knew how broken system was until they were educated by us marriage Jack and our story. So then what happened was I basically went around and I said, Hey, guys, I am so sorry, I didn't actually mean to raise at 1.5, I actually was hoping to raise a little bit more money, because it appears that there's a lot of people here who have similar thoughts to you, which is, let's fix this broken system together. And I want more people like you around the table. And that's how we ended up raising the remainder of the money, which was $4.7 million in the end. 


Griffin Jones  28:19

That's all from one round? So it was about that the seed round? Or is the second one an angel round? Or tell, tell us about that?


Dr. Brian Levine  28:26

I mean, I think the nomenclature people use all the time, it's just silly, but the initial was about 500. The next one was around 4.2, in the end, that we raised. And so you add all together, there's your four, seven, but you called you know, initial capital, and then he called Seed past that, but we haven't done an A, obviously, is that coming next? I think the future is a series i i have some very specific KPIs I'd like to see us hit before doing a series I think that in this current economy, need to be so respectful of the markets. Because we're in a weird time, I was incredibly lucky that I started a company in a very favorable economy. And if I would have started this company six months later, or a year later, I don't think it would have had the same success in my fundraising opportunities. And so to me, I'm actually going to set a very high bar for the Series A, which is gonna be important. The most important thing for me and this next round of funding that we hopefully will do with our Series A is that the VC partner that we picked to do this has to do this with someone who wants to be our partner from the A to the B, someone who wants to be our partner for the big picture for the long road who's willing to be there as a partner, shoulder shoulder. And of course when you do a series a with a lead, that ends up becoming the most important individual because you end up usually having them be a board seat member. And I think a board seat members are working board seat, and that's really important to us. I'm making a note because I want to talk about what that Working board see my look like and how you select for the people that you want to be on your board. But let's talk about those KPIs is that there's certain KPIs that you want to hit before you raise more money. Tell us more about those. So again, it's in partnership with the right VC and the right time, but I think there's gonna be certain dollar amounts are gonna be certain volume of mounts, you know, doing enough matches, making it up, or producing enough revenue, being profitable. There's certain numbers we have to hit before we actually get there. Are you giving yourself a timeline, or is the money that you have the timeline, so the money that we have right now is given us a good amount of runway. And we're in a really good spot right now where we're comfortable that we can keep building and scaling and growing with enough runway to go. And I think, from a big picture perspective, we need to take a, I'd say a top down view of how the markets are looking and how the partners are looking, right? It's all about finding that not just product market fit. So finding that company market fit. And timing is everything. And so I'm a very patient person, as I think you know, and so I'm willing to be patient to find the right partner at the right time to do this successfully. And quickly.


Griffin Jones  31:08

Let's talk about what you want that partner to have. Because partner is one of the most ambiguous words in business, the word partnership is so ambiguous, one of the things that I'm writing in our editorial guide is inside reproductive health expands news coverage, not just the podcast, but covering the trade media happening on the business side of fertility field, and writing this so that the journalists know, the word partnership is used all the time, you have to figure out what it actually means. People say partner, because they don't want to say they bought a company when they acquired one, it can mean a capitalist merger, it can mean no merger acquisition whatsoever. It's a strategic partnership, like a joint venture. And so when you say that you want, you're the the firm that ends up leading that series A to B with you from A to B, and ultimately, to serve on the board and to be a partner with you what specifically do you mean?


Dr. Brian Levine  32:05

I want that individual company to put enough capital and that they have a real meaningful ownership opportunity in our company, where they will get to enjoy the upside, and the win. And that they will also feel like they're taking risk with us. So they understand the importance of that investment. But most importantly, is they're completely aligned with our success. It's easy to write tickets for someone to write a check, it's hard for someone to come up to four board meetings a year, it's hard for someone to be in the in the dugout, and in the trenches. And to actually give real critical feedback, we want someone who's not just gonna say, hey, everything you do is great. We want someone who's gonna say what you're doing is good. But we can get you to great if we scale you in this way. And we need someone who has experience


Griffin Jones  32:55

You have someone with experience in the reproductive health space, or within healthcare or tech or what kind of experience?


Dr. Brian Levine  33:03

So I think it's, it's different, right? So every VC has a different, you know, flavor, and a different approach. It's about finding a VC that is willing to be nimble with us and patient with us, but also has experienced in scaling marketplaces and healthcare to the right place.


Griffin Jones  33:22

When you're approaching the the next phase, what do you find yourself learning the most about now? What What have you spent the last month or two studying the most with regard to new concepts or, or areas of business? 


Dr. Brian Levine  33:37

I love this question. Because I would say that for every 100 questions, I get 99 knows, which is the best, right? You know, you talk to someone, get feedback, talk to a company feedback. So one of the things I do is I I've joined a support network of other entrepreneurs and founders to ask them and to learn from them, because we're all kind of going through this crazy founders world together. And so learning about just other companies and how they've grown and how they've scaled and how they've become a little more market resistance, a little more tough on his time. But for me, actually, I'm really obsessed right now with studying elder care. I've been studying elder care companies for the last six months. And the reason I've been studying elder care is that in this country, there's a lot of great companies that are out there that are helping address loneliness. And they're helping do case management for the elderly. And insurance companies have really helped these companies scale in a meaningful way. That's really cost effective. And I view a lot of parallels and similar as to how we take care of elder care and do case management and social work care for the elderly, and how we can actually manage circusy in a digital transformational platform. Learning to look at actually how we can do case management light instead of doing the traditional analog system. How do we digitize this? How do we do high touch high feel How do we take care of grandma safely? Using a digital tech platform? Well, why can't we just turn that upside down and read instead of reinventing the wheel, just retool that wheel, and figure out how we now can do that for the surrogate, but the gestational carrier for the intended parents. And so I've spent a lot of time studying elder care right now. And studying social work, and studying case management systems, because I view so many parallels between that and the system of surrogacy. 


Griffin Jones  35:31

Oh, interesting. I wouldn't have thought about that and go looking into elder care and social work for the purposes of learning more about case management. How are you taking in the information? Are you just following blogs of people that lead in the space? Are there books out there? Are you trying to dig into company records that are public? Are you one of the guys on the other side of the consulting call that you and I both get some times when it's people entering the reproductive health space? And you're on the other side of that call calling people that are in the elder care space? How are you taking in the information?


Dr. Brian Levine  36:06

 So I won't deploy capital for those consulting calls, because they're really expensive, so much that I do one better. I go into websites and find the founder. And I just ask them the honest question. A I'm not in your space. I think there's some parallels here. Can we do a 30 minute chat. And I reached out to everyone, and I dig on LinkedIn. And I dig through website, and he just cold email people. And a lot of them are met with no response. But some of them are. And so there's a company out there called Papa that I'm absolutely obsessed with. And I met with Andrew and I got to talk to the founder and talk to him how he did and how he scaled his business and his b2b solution and how he was able to take this company from, you know, dollars to hundreds of dollars to 1000s to millions to billions. And you know, how did he get his valuate from that, but what did he do? And he and I now have, you know, bonded over this. And, you know, I talked to someone who did this and another service profession, I talked to someone who just did, you know, a mental health platform for management for psychologists for writing notes. Because right, every surrogate needs psychology screening. And if we could figure out a way to digitize a lot of this analog stuff, we can make it both reproducible and reduce the cost and make it safer. And so it's all cold emails, and cold calls. And if I find a phone number, I call it and find, you know, phone number, I typically try to text it first, and LinkedIn, and anything that's free at my fingertips. 


Griffin Jones  37:32

How are you balancing this new pursuit that you have with your current business with your current role as a an individual contributor and a manager in your current business, not just a part of the not just part of ownership? And you're proud dad, I see you on LinkedIn, you're a really proud father. How are you determining what amount of time gets allocated and where?


Dr. Brian Levine  37:59

I set boundaries. And that's been really hard lesson for me this year. Last two years now, I set boundaries about everything. I'm here, I'm here, when I'm in my office, seeing patients I'm seeing patients, I don't get distracted. And I have a full schedule. And I see patients, you know, I still put in my 40 hours a week here. But then when I finish my day, my clinical day, I'm 100% nodal nondistracted. And I have an incredible team. And we now have 15 people. And our team communicates through slack, which is an unbelievable asynchronous tool for allowing for continuous communication throughout the day and night. As you probably know, I'm a painful early riser. So my morning routines have been optimized allow me for jumping into notable for anyone else's awake, when I don't eat much sleep. So most nights at home, I'm at home on the computer once I can get my kids to sleep. As you know, bedtime is incredibly precious to me. So after bedtime with my kids, I'm on nodal. And what I'm able to do is because I have an incredible team of people who help support each other, and I'm able to impart the clinical side of it, it works. This is not the model for everybody. But for me and for the nodal team. It's been an unbelievable way for us to build and scale this business.


Griffin Jones  39:17

You have a lot of venture capitalists listening to the show, you have a lot of executives listening to the show, but I'm thinking mainly of your colleagues, many of the RAS who they will tell me over a drink. I'm thinking about this, you know, there's something that's bugging out and that sound like it originally bugged you. Let's conclude with that thought, how would you like to conclude about starting an entrepreneurial venture within the field of reproductive health, but is isn't building a clinic? It's building a different kind of solution. How would you like to conclude with that theme to that audience?


Dr. Brian Levine  39:54

So as doctors, we spent our entire lives educating our calls and training to solve problems that are put in front of us. Don't let yourself get pigeonholed to only clinical problems. Take a step back and look at the systems that we work within. And I think the best advice I can give everyone is find someone who's willing to say no, but someone who's willing to say yes. And so the reason I spoke to my friend John to ask him about starting nodal, and telling him about the problems and him telling me start a company, and then I spoke to my friend Scott saying to him, Scott, tell me why shouldn't do this. You got to find people are going to be honest with you. And make sure that you can describe your problem to a lay person and let a non Rei let a non doctor, not your spouse, kick the idea around, of course, talk to the people within your clinic and network, make sure this is kosher and okay with them. Right, I had made sure that I talked to everyone here and made sure everyone knew what was going on. And I've been completely open and transparent since day one. But most importantly, you don't get to become an REI without a lot of support friends and family. And what I learned from starting nodal was that I had a lot of support around me. And I have a lot of support around me both for CCRM and also now for nodal and it's super exciting. So tackle those problems, because there's a lot of them that need fixing.


Griffin Jones  41:15

Dr. Bryan Levine, thank you very much for coming back on to Inside Reproductive Health.


Dr. Brian Levine  41:20

Thank you, Griffin. This is always so much fun. It's great to see you.


Sponsor  41:23

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

186 How Fertility Centers Can Save (Patients’) Money, Line By Line with Dr. Mark Amols


Let’s save you and your patients some money!

From the materials you buy to the software you invest in, it can be difficult trying to find where to safely and effectively reduce, replace, or eliminate to save money and maximize your practice’s bottom-line.

We talk with Dr. Mark Amols, founder of New Direction Fertility Centers, and he walks us through his low-cost affordable IVF model. He reveals where and how he invests, or doesn’t, to keep his practice thriving.

Dr Amols breaks down his four categories when purchasing materials and services:

  • Which line items can be completely eliminated

  • Materials that can be reduced or replaced with cheaper alternatives

  • Finding cost-effective versions of necessary commodities

  • How to know the expensive must-haves to pony up full price

Dr. Amols opens up his playbook and gives specific cost examples from his own practice, so listen in and see where you can cut your bottom-line.


Dr. Mark Amols’ LinkedIn
New Direction Fertility

Transcript

Dr. Mark Amols  00:00

There's nothing special we're doing. I mean, this is typical supply and demand type of economics and in when it comes to the vendors, I think one of the most important things that I do as a business person is I don't look at it as me trying to get the lowest price. I don't try and get the best deal. I kind of look to the vendor, I say, how can we work with each other?

Griffin Jones  00:28

Let's save you some money. Let's go through your income statements, fertility doctors, let's go through your costs and see how we can save you money by eliminating, replacing, reducing, negotiating. But before we do that, I have to fess up to some technical difficulties that messed up this interview a little bit. It was my part I know that breaks your heart, you're not going to get to hear all of my witty insights the same as you would if the recording for the audio went properly. But Dr. Amols who was our guest, Dr. Mark Amols from New Direction Fertility in Arizona, gave us so many good insights. I was late to the interview to begin with, but no good excuse just my carelessness, I didn't want to have to bring him back on for his time for the audio issues that were on my end, but my audio stopped recording about a quarter of the way into the conversation. So I re recorded my questions, I tried to do my best to match them up with how the conversation went. And the answers that Dr. Amols gave, if any of the answers seem off, blame it on me. But the insights in this episode are terrific. I asked Dr. Amols to walk us through his low cost affordable IVF model that he's had a lot of success with in the Phoenix area, I have him go through those things that he spends less money on things that he doesn't spend less money on in his system for approaching that I definitely wanted to have him back on for another conversation about top of license, not just the REI, but everyone in the fertility practice, going through the accountability chart and what that would look like. But today, we focus mostly on materials and services. And we break those into four categories. The first is those materials and services that you just don't need, you can eliminate those costs altogether. The second, which ones can you reduce or replace with cheaper alternatives? Because you're reducing them in some way? The third is those commodities that you need them. But there's a wide range of prices and not a wide range of quality. So how do you get the cheapest? And then the fourth, maybe there is a wide range on prices, maybe there isn't, but there is a wide range on quality. And you really have to pony up sometimes. So we break into those four categories. We also talk about things like software and professional services. And Dr. Amols is very generous. In this episode, he gives specific examples, he gives specific costs, he opens up some of his playbook very transparently. And he shares that with you. So if you talk to Dr. Amols, please tell him thank you because I want him to come back on and share more. But I also want everyone to come on and share a little bit more. And it always pushes the envelope when somebody's willing to just share a little bit more makes that episode that much more popular, more valuable. And then people want to mimic that and they tend to share more valuable information and give more value to the audience when they come on. So enjoy this conversation with Dr. Mark Amols, Dr. Amols. Mark, welcome back to Inside Reproductive Health.

Dr. Mark Amols  03:28

Thank you, I greatly appreciate it.

Griffin Jones  03:31

I thought to invite you back on because I was in a meeting not too long ago, with an older physician who was expressing distress in their voice, I could hear how troubled this person was that they wanted to reduce costs at their IVF center because they wanted more people in their area to be able to afford treatment. And they legitimately did not know how to do that they're already being squeezed on the margins, I could see their numbers. It's not like they're raking in a whole bunch that you know, it's just coming out of a inflated top line for them. And there's been a handful of people that have been able to do a lower cost affordable IVF model in the country, only a handful. And you're one of them. You've been on the show to talk about that for and that's still one of the most popular episodes. And I remember at that time we did it live and it was during the COVID shutdown and we had more people than we had capacity for in the Zoom Room we had we had to you know upgrade our our account. And so I wanted to have you back on and I wanted to go through with you how you select your partners, meaning your strategic partners, your vendors, because a lot of people would like to be able to lower costs and they just feel like they're getting squeezed everywhere. So how do you think about this challenge?

Dr. Mark Amols  05:06

Yeah, you know, it's interesting when you told me about the topic, I was kind of confused when he said, How do I choose my vendors, but it actually does all come together? I think the question isn't so much how we do it. But why other people can do it, there's nothing special for doing I mean, this is typical supply and demand type of economics. And in when it comes to vendors, I think one of the most important things that I do as a business person is I don't look at it as me trying to get the lowest price, I don't try to get the best deal. I kind of look to the vendor, I say, how can we work with each other. And so for example, like I understand the vendor has shipping costs. So if I want them to send me something every month, I realized that's gonna cost them more money. So I'll work with them say, hey, whatever, I just take like two large shipments a year, I'll take a huge volume, you give me a lower cost. Now you're not paying shipping all the time. And I'm, you're guaranteed dismount every time I'm again. And so that helps kind of like, you know, look at it as a relationship in that standpoint. But the other thing is, is I understand the point of volume. So when you're talking about low costs, I mean, it to go like Target and stuff, you have to have more volume, if you don't do more volume, you're going to lose. And the way that traditional IVF is set up is really this kind of, you know, we're gonna get 1020 patients in per month to do IVF. And so they rely on making a lot of the sale, and they don't have the volume. And so when you do have the volume, or at least if you're going to have that volume, you can go to these vendors and say, Hey, here's my volume, here's my projected volume, you can see how much growing each year. And I tell them I say listen, if you make a deal with me, and help me, I will stay with you. You know, even your prices go up a little bit, I'll stay with you. And so down to the vendor pick, like we were saying, so getting back down to how do I pick my vendors, you know, it depends on your product. So there are some products that are made by multiple vendors. There are some products that are not right. So if you think of, let's say, fairing, or you go up at the end of the men's out there, that's like the electric company, you really don't have a choice, right, you only have a choice between Gameloft and follistim. But when it comes to manufacture, you really don't have a choice. So for those type of companies, there's really not much you can do that the relationship is really just them being nice to you and your stuff to keep buying their product, but with Folsom and go limp off, so you can work with them to try to get better pricing for your patients. When it comes to things like product for the lab, you're a little bit limited, because there are quality differences. Luckily, it's been very standardized in their industry now. So you know, most we're using the same products now. But with those vendors, it comes down to, I think building some type of loyalty with them. So you know, you work with a company every single time they know you're going to come in and buy, you know, six ultrasound machines, you know, 620 incubators the same time, they're going to, you know, keep giving you better prices through the years because they know you're gonna stay with them. And again, building that relationship with them, you know, always sending stuff that way. And then the other vendors are going to be your vendors that have multiple vendors that do the same thing. So when you talk about things like speculums, or you talk about things like drapes, you can get drapes from multiple companies, there's stuff I buy off the Amazon, because it's cheaper for me to get them off the Amazon than it is through my suppliers like Henry Schein, they have tegaderm, which goes on the skin after you put an IV in. Bye bye for them. It's like 100 bucks for 100 of them or 80 bucks. I got off amazon for $15 the exact same things. So when it comes back to choosing the vendors, going back to that question of how do we make it work? So one of the things is, is I tried to find those strategic partners. And and I talked to them like they're a business, I don't talk to them, like I'm trying to buy their product. I taught them to say Listen, how can we both help each other? What do you need me to buy? How much have you need me to do? Because like there's things I want a lower price, I'll go to come I said I need this at a lower price. And they said, we can't go any lower, it's okay. But if you buy more of this, then they'll offset I can lower that price. And so again, it still ends up the same, right? We're still looking at the same thing, which is overhead, which is your expense versus what you make. And that's really all it is. It's just the differences. It's harder to do. So I'm not trying to say that about most doctors, most doctors don't want to do business. I mean, why would you still want to become a doctor, you want to go out and just make money. And so for most people, they see money in their bank account, they're happy, they're like, it's going up, I'm happy I see the numbers going up. But that doesn't mean they're efficient. That doesn't mean that they've actually at the point that they're getting the most amount money they make. I can almost guarantee you that if they went and got a person like you know, Scott Robertson, you know, from practice up, they got him to go through their practice, I guarantee they'll make more money just by him going through and finding out where they're wasting tons of money. And so in those situations where you have those practices that already have this high overhead they're trying to do this low cost model, but they're not efficient. And that's really that the main thing is you have to be efficient, and there's more to it, we'll go over that in a little bit more detail. But that's really the biggest thing is when you're looking at vendors, you're trying to make sure that, you know, you pick vendors that you can build that relationship with. So you can get lower prices and be able to offer things you know, better cost. So things like speculums. I mean, I, my spec homes costs, I think some like 10 cents. Whereas like, when I was at another clinic, it was a buck 50 per speculum, and it wasn't needed. And so again, there's things you can do to get better pricing, that doesn't matter. No one's gonna have a bad idea of cycle because respectable isn't great. But they aren't going to bear the IVF cycle, if they're incubators bad.

Griffin Jones  10:47

So I do want to go through those different categories of what's more interchangeable versus what you think is less interchangeable, and I want to break up those different categories. First, I want to think about how do you approach looking at this systematically? Or do you like do you do you just start to negotiate and look for different options? When you're ordering something? Do you go through your p&l at different points of the year and, and go line by line and say, How can I start with this and go all the way down the spreadsheet? How do you approach it?

Dr. Mark Amols  11:21

Yeah, every three months, I go through and I look at everything that we order. And I find out if it's one of those categories of where we can't change, right, there's no option. It is something that we can change, but we can have very little room because it might be something like an incubator, I'm like, I can't go for the crappy incubator, or is it something that's easily changeable, like a drape or something like that. And then what I do is I always go through and look for the best price. And so for example, like propofol is one of the drugs we use for anesthesia, I found a way for us to get propofol at 20%, the cost we originally paid. And again, it doesn't sound like a big deal. Because most clinics, if you're only doing 10, 20 cycles a month, you're not going to notice a couple of dollars here and there, when you started doing 100 Something a month. Now all of a sudden, that becomes several $100 Every month in that one product. And so those little differences make, you know, make a big difference. And so yeah, I go through every every three months, I look at things, I'm always looking for ways to reduce costs. Here's example. So one way we reduce our costs for bloods by 50%. So we made more margins was I know this, we were buying 10 milliliter tubes to fill the bloods up. And then one day, I was wondering, they make smaller tubes that cost less. And we went and found that they make like four milliliter or five milliliter tubes. And so we went and got five milliliter. And then later we found even made a smaller tube when we run like six tests in our clinic, so we realized we could use less blood, it costs half the amount and we reduced our costs overhead for those supplies by 50%. So just things like that, looking for things, looking at what do you need? And what are you getting, and you may not need what you're getting, 

Griffin Jones  13:04

I would love to have you back on for another topic to talk about top of license throughout the accountability chart. So you and I can go through the accountability chart of fertility center together, because we often think of top of license as just the REI. But the whole purpose of getting someone to practice at the top of their license is to get the next person to practice at the top of theirs down to the person that is checking someone in and bring someone to their room.

Dr. Mark Amols  13:32

So it means a culture, right. So as a culture as a clinic, we all believe in the same thing, which is making this affordable. So everybody knows that the better our overhead is the lower we can keep costs for patients. And so my lab, you know, will always look for the best price and other times they'll come to me and say this is all we can do. And I say okay, let me look at it, I might look into a little bit more. I have to be very nerdy. I love numbers. Like a dat in there. So I love that stuff. So I enjoy doing it. But yeah, I have other people who will do a lot of that for me. And then when they can't, they'll come to me and but I'm I'm always thinking of ways that we can reduce costs, just because our field I do believe has a lot of fluff and a lot of overhead. It's not needed. You know, we made some big changes just recently on just even staffing away I thought the box of we have staffing our clinic different where you know, medical assistants are very difficult now to find. And you know, I kind of looked into the legality of like, do we really need medical assistants for every little thing and so we found out that we could even just put greeters out there who can help us just you know, put patients in rooms and then again, that brought cost down so it's just it's not resting on your laurels and just saying hey, this is what we're gonna do. It's always gonna be this way we're always changing and adjusting. Same thing with vendors, you know, always looking at different things. Now, there's the point where again, once you have that relationship, you know, if you're constantly just changing for the lowest price, well then no one's ever gonna work with you. So I mean, there's a little bit of flexibility you have to have right so if someone's give me a great price now and then two years later that go up a little bit. And they're a little bit more than next one, I'll still stand with them. Because at that point, I know I've built that relationship. And again, that's an I'll talk to them and just say, hey, it was a little harder than we need. Is there anything we could do to get that down? Can we can we purchase more at one time? Can we do this stuff like that, but things like there was little things like shipping all those different things working with your vendor, you can get better pricing by just working with them and ordering more and committing them more. So

Griffin Jones  15:25

For the sake of this topic, let's break it into four categories, those costs which you can cut, eliminate entirely those which you can reduce significantly, either by replacing them with something else or reducing them by a lot. Third, that which is a commodity, you need them. But you can find a wide range of prices for not a wide range of quality and that fourth category, those things that really matter, there might be a wide range of prices. But there might not be and there certainly is a wide range of quality. And it's too significant. 

Dr. Mark Amols  16:01

Exactly. 

Griffin Jones  16:02

What are those costs that fall into the first category that you can eliminate entirely. 

Dr. Mark Amols  16:06

One of the things I when I was in other clinics, you know, obviously did this with one person training and then prior business I was with, is there was a lot of stuff we did to make, like a few dollars, but wasted a lot of our time, I think the thing that's most important understand is there's only so much time in the day, right? As a physician, I only have so much time, I'm probably when you think about when it comes to resources, the most scarce resource in the clinic. And so what happens is, is that there was a lot of stuff I was doing as a physician that made absolutely no sense. So we used to do what are called IVF consults, where we would sit there and go over the whole process with the patient of the IVF, we used even do a surgical visit the day before then make an extra dollar or two through the insurance. The problem is that same hour and a half being used for retrievals could do three retrievals. Or I could do two consults. And so one of the things that can be thrown away is really using people who can do things in their category. So for example, there are things no one else can do that I can do right as a fertility doctor. And so those are under my license, any nurse can do those things I was doing before those other clinics. And I can guarantee you there are claims out there today, where the physician is still doing a ton of stuff. And there's no reason to do that. It's a waste of money, it's a waste of your time, you'll never build do this low cost money, because you're looking at going, I gotta spend all these different employments eight payments, before I get to this point. Now you don't you have a team that that can do this stuff. And so part of what's important is, is you want to utilize people to the max they can be what's the most are allowed to do as a nurse. And then but you also don't want to waste their time doing things that you don't need to right because you're paying them too much. So when you look at overhead, so when you talk about what can you get rid of, it's for not getting rid of it, but adjusting it to out of the wrong hands instead of the doctor bringing it to the nurse, bring it to maybe you have a specialist, that's all they do is bring in someone, let's say off the street, you pay him 16 bucks, Darren, you're like, you teach them everything about IVF, you say this now is our IVF consultant, and they're just going to tell them about IVF. And you know what, they're gonna be pretty damn good at that job. You don't have to pay someone $80,000 a year as a nurse to do this every day when someone else can do it. And they'll do just as good because that's what they're specialized that that's kind of the way I look at things when you're looking at these models. I think one thing that's really interesting, though, about our clinic versus some of the others is that I think it's really important, though, to stay a high quality clinic, you know, not seeing other claims are bad, and I won't name the clinic. But there are a lot of people who do what I do, and have very poor pregnancy rates. And there are clinics like me who have very good pregnancy rates. And I think that's really important in this big thing. So when you're doing all these things, you're making these adjustments, you don't lose being a good clinic. You know, it's not about just getting low cost and having bad service, you have to stuff that service. So all these things I'm saying when they take them out. It's not that they're there's none important, like I said, so one of the fluffs I always talk about is like, most people don't want to sit there for an hour and hear about the idea of like, you know, the prepper rather read it on paper or give it to him in a text or something like that. So just stuff like that is how I've taken those things out product wise, is more just choice. Some physicians like use an iodine, you don't really need iodine. There are other changes you can do, but those are very small.

Griffin Jones  19:24

How about the second category that which you can reduce quite a bit or swap it out for a much less expensive alternative?

Dr. Mark Amols  19:31

Yeah, I mean, a lot of the things it sounds crazy, but like going from four by fours to two by twos for certain things, you know, we just did it away. We we always did it one way needles. You know when I'll give you example, one thing that a lot of clinics use, is they use other fine needles. Butterfly needles are really expensive. I mean, the best price you're gonna get for them. It's maybe a buck, but usually they're like a buck 52 bucks. You go to a regular needle mean the pennies and so Oh, you know, you think about your doing 1000 or 2000 needle sticks, you know, every few months as 1000s of dollars versus a couple $100. So that's something where, you know, we still had those if needed, but any phlebotomist knows what they're doing does not need to use a butterfly. But yeah, clinics use up you can get skinny needles that are still butterflies. So another example, too, was not only going from the five milliliter tubes was a big difference. But we actually found out that there are other brands of the tubes. And so a lot of people when they use like tire top tubes, most expensive from you know, Beckman, but you can actually get these ones caught we call McDonald tubes, or they look like a McDonald's franchise, too. And those are when I say lower costs, like 1/10 of the cost of the other tubes. And so again, something as simple as that can save a ton of money.

Griffin Jones  20:56

And how about that third category? Those things that you definitely need, but they're commodities, you can find them from enough for a number of different vendors for a wide range of prices? How do you find the best price for those?

Dr. Mark Amols  21:08

I think one is, obviously you have to have a company where you can keep looking at you have to look at see if they have multiple companies that sell that product. Now, here's an example of drapes, the pads the patient's sit on. So we were buying a certain size, but they were kind of too big. And I found if I just get a size, it was like two inches smaller, we see it like half the amount. This is like little things like that, and always ask them the question of do we need that, we obviously need the purpose of protecting the patient so that you know, but not sitting on a drape. But if it's falling over the sides, well you can wear when there's two inches smaller. And now you see a cat and mouse like little things like that that we look at. One was a male stands we used to use Mayo stands all times when you do surgery thing called Mayo stand up, put up a sterile drape over and then that way it protects anything on which you obviously want to have is sterile. But then one day I was I was wondering why why are we putting a male stand that we put a sterile thing on top of already when we open up the instrument. So instead, what we did is we took our instruments by a slightly bigger kind of like the truth that we cleaned it with, put it on there, we opened it up, and now that becomes kind of our sterile drape. And we saw at the same benefit, as if we were being the man stamp, but we're paying a fraction of the cost. And again, we're not losing a sterility, everything's still the same is that we just use the drape that it came with that we have everything cleaned in sterile area. I think of other things where we've we've made some changes to sorry, is that there's a lot of things I mean, but you know, those are kind of some of the big examples of you know, things where we would just look at everything. Here's another one, I just thought one was a probe covers. So when you buy pro covers, if you buy them in bulk, you get a huge difference in costs. If you just buy like the 100 pack every time you pay a premium, but you can buy like 1000s of them in bulk, and they're clean. And then that way you just put those in into your rooms and then use those. So again, another place you can save a lot of money. I think the big question for speculums is you have to ask what what your volume is. So if you're only doing let's say, five a day, you're probably going to save more money than using something like a reusable one and just you know, clean them but that takes money cleaning those it takes a person cleaning them in a busy clinic like mine, that could never happen. You have to use disposable. And like if you use the common disposable, you'll pay a lot of money. So here's one I'll give away. This is a good one people really like so if you buy Welch Allen lighted speculums they're very expensive. The light that goes in them are very expensive. Everyone loses those all the time drives me nuts when my nurses there were some because they're like 300 bucks for those lights. The speculums themselves cost about once you about $5 Each speculum. So Henry Schein makes another version of it. But the problem is, it's a wired version. So the problem is you have to put a wire into it which is which is horrible. You want to have it you know portable. So there's a company that actually makes a little light that fits into the Henry Schein when I figured it out. And so we were able to buy all the lower cost Henry Schein lightest speculums and use a disposable light. So the best part about it is, is that if a man loses a light, it was just 10 bucks on that light. And the second thing is we reduced the cost by half of our speculums. Just another thing I found by researching things though, it's not always just the supplies you use, but also the time committed to it. So for example, like a Sano histogram, way most clinics I've seen do it, they by saline models, they pull the ceiling up into a 10 cc syringe. And then they go and they do their solo histogram pushing with the st lame. When we used to do it that way. We had to do solid histograms about every 15 minutes. And then I found prefilled syringes, and I thought well if they're more expensive, we're gonna pay more, but then we'll have to To time into it and said, How fast can I do it? We're using everything prefilled we end up doing them every eight minutes. And so again, one of the things you also look at is not just the cost of them, but you're also looking at, does it make it more efficient. So we switched over now completely to prefilled ceilings. And back to that thing where I said about the 10 CC's. So we were just buying 10 CC's for everyone. And then I went spoke to the nurses, I said, Well, how much do you use, they go, Oh, we only use about three or five. So then I went looked up and found out they make three or five milliliter ones, or those lower costs, and they were so at that point, okay, oh, by the lower cost ones. And the same thing with like propofol, people, when I got the better price, one of the things I found out was sometimes when they're given propofol, they open up a whole nother bottle for just a tiny bit. I thought, well, one of the really tiny bottles so that way, we don't waste so much medicine. And they did. So we bought those. And so then and this is all just these need a little bit more use smaller bar, which cost less. And so it's not always just about getting a different product, but finding out are these these little areas that you're not using so much, you know, and stuff like that is really how you do it, even on the pay what you do each ESGs for, there's several bottles, and you'll find that there's one bottle, it's about a third the cost. So so back to that fourth category. Yeah, you know, again, I think it depends on how you look at your clinic. And that's why I made that point. They were the biggest difference or clinic, we have, we have to have high quality, I feel like what good is do they have a lower cost, and you're just gonna have bad rates. And so the things that I feel like you can't come away from are some of the main products, you know, good incubators, you know, you really have to be up to date on their incubators, I think there is some adjustments you can make between them. But you know, I feel like, Sure, you can get a cheap pair cell incubator, but it's not gonna be the same quality as a benchtop incubator. Same thing with things like gases, you know, I would love to be able to use cheap gas. But you know, you're not able to if we're using mix gases, we, you know, we have to have it certified, that we did find another company again, for cost again. So we always are working on that. And we're even looking at now mixing our own gas to save money. But but the point is, you can't, you really can't do much, you know, now there is like, like I said, when it comes to medicines of it, you can't change that. There's nothing you can do the company. But when it comes to things like incubators, you know, we look at a lot of things, we buy a lot of them so we're able to get good deals. But there's really not a lot of like I said adjustment. I mean, other than when you want to be one of the top, you have to use some of the top stuff.

Griffin Jones  27:29

What about other costs, particularly related to your tech stack things like your EMR, your payroll, software, other software, your billing and scheduling software?

Dr. Mark Amols  27:38

So EMRs I feel they all suck. I don't think there's a good one. If anyone says they have a good one, I want to know about it. But I don't believe there are any good ones. So when I looked at I said, well, listen, there's no good ones, I'm just gonna go with something that gives me the fastest speed. So we went with a system called Dr. Chrono. And what's unique about it is is you can do the whole thing on the iPad. And it's very fast. It's not made for fertility, we're actually trying to make a component for for fertility. But so we went with that, but it's free, doesn't cost me anything. So my EMR costs nothing, they do my billing for me as well. And take the same fraction amount and take it from any other biller. So we just use a company, sometimes there's some things that are cheaper to do when you outsource until your volume gets high enough. So obviously, like a big company, like Pinnacle or CCRM, right, forgive them when they charge and stuff. But for smaller places, it's actually cheaper to just find the company that will do it, than hiring someone to do it. So we do all that outside. 

Griffin Jones  28:36

How do you approach paying for professional services? Things like business consulting, marketing, consulting, accounting, financial consulting, legal expertise? How do you pay for professional services or think about costs, like, associated for those?

Dr. Mark Amols  28:53

So because I like the business side, I do a lot of it myself. Honestly, I only have so much time in the day, I do have a CPA. So my CPA does all my bookkeeping does that. We do have a legal firm that we work with all the time if needed. Luckily, we don't have to use them a lot, except for all the expansion we're doing right now. And through the other cities, when it comes to financial stuff like that. I do a lot of that myself. We don't do much for marketing. Luckily, we're very fortunate that we don't have to, but I do do my own marketing when it comes to things like Facebook, my podcast.

Griffin Jones  29:25

My recommendation for professional services is to separate them into sporadic engagements whenever possible. So sometimes you need professional services for execution, some marketing services, some things that you might need for legal help in terms of drafting documents that are pretty easy to do here and there. Just the drafting part of it. I'm talking about things that you might need accounting services like bookkeeping, those ongoing things. Try to minimize those costs as inexpensive as you can and then be willing to pay for professional services as at a high hourly rate. That's something thing that I do now I charge at a higher hourly rate. And I could do packages and things, but that allows people to engage us at a rate that works for us because they're paying high by the hour, but also works for them because they don't have to lock it in every month. So go ahead, pay for expensive business consultants, expensive legal consultants, but try to separate that from the ongoing costs of monthly implementation when possible.

Dr. Mark Amols  30:25

Recurring costs are one thing that can kill a company. And so you know, you're hitting right on your right things like consultations, you don't need recurring forever, but it's worth getting the best when you do it. And usually, that does cost more. And you know, now that we're doing all this expansion, we use lawyers more. And so we've been looked at potentially going to have an in house lawyer, but again, recurring costs get expensive. And so I agree with you 100%. on them,

Griffin Jones  30:50

You're still independently owned, I sometimes see independently owned fertility practices having more leverage because of consolidation. Because there are fewer people to buy services, there is more emphasis on those buyers that remain. And so even if you're not the size of the networks, as an independently owned, Fertility Center, do you have more leverage, because everyone else is consolidated? And people have to make deals with those that remain? Or am I fantasizing too much about this? 

Dr. Mark Amols  31:23

You know, I think, again, comes back to that slide the man or thing, right, so if you have a clinic that's not using a lot, I mean, I don't know how they're gonna be able to really get best prices and things like that. I think clinics that do more, you give example I see and why and you see why it's humongous, or I'm in the summer, like 4000 retrievals a year, they're able to get the best pricing just as big as like a pinnacle or CCRM. You know, and so I think I would tell someone, if they're trying to do what I'm doing, is I think the most important part is explaining, show them your growth, right? If you can show growth every year and say less number grow in play in expanding, then you become kind of your own group, you know, Purchasing Group, and you say, Listen, every client I opened up, I'm gonna still order from you. And that helps it one of the things that you I think you and I spoke about one time is why not all the little guys teamed together and make one group you know, and then that way, we'll be our own Purchasing Group. I think it's a little bit fantasizing, I think, as a company, if I was a company, and symbol was so low, and they were doing a lot, I wouldn't give them lower prices, you know, because that's the only reason you're given the lower prices at the bigger companies is because of the volume they're doing. And it just wouldn't make financial sense to give it to someone who is using very

Griffin Jones  32:33

Giving us really specific examples. You've also given us a framework for practice owners to go through their own books and see how they can lower costs, how they can increase profit for themselves and ideally pass on a lot of those savings to patients. How would you like to conclude?

Dr. Mark Amols  32:52

If anyone's ever interested in learning about this, I mean, I don't try to hide at this you know, I'd love for everyone to make fertility more affordable. And I think there's always going to be those niche, you know, offices that offers you know, that one on one the whole time process with with a doctor and those are going to do great, but if anyone's ever interested, I'm more than happy to talk to you if they want some of the ideas. I have the reduced money costs, you know, on their overhead, more than happy to talk to you about but hopefully I was able to help some people.

Griffin Jones  33:20

Dr. Mark Amols, owner of New Direction Fertility in Arizona. Thank you very much for coming on Inside Reproductive Health and I look forward to having you back on for another topic very soon.

Dr. Mark Amols  33:31

I look forward to it.

Sponsor  33:33

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

185 How to Increase the Number of REI Fellow(ship)s. And some ideas for Funding with Dr. Rachel Weinerman


Everyone says we need more REI Fellows, but how do we get them?

In this episode, Dr. Rachel Weinerman sheds light on what is required to make more REI Fellowships and Fellowship Programs, and why those two solutions aren’t exactly the same. Dr. Weinerman talks about:

  • Creating REI fellowships: Exploring the steps in establishing robust REI fellowship programs.

  • REI fellowship funding and operation: What Medicare pays for vs what the institution pays for.

  • What an REI must do vs what another ‘IVF specialist’ can do

  • Specific resources that SREI and ASRM can contribute to Fellowship growth

  • ACGME’s role vs ABOG’s role in accreditation and certification

  • The limitations and scarcity of Privademic Partnerships


Dr. Rachel Weinerman’s LinkedIn
Company Website: uhhospitals.org

Transcript

Dr. Rachel Weinerman  00:00

So where are we now in 2023, we have comprehensive training programs that train OB GYN who are already fully trained OBGYN to become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and portfolio positions. This is very different than training an IVF physician


Griffin Jones  00:28

Who the heck is going to pay for all this? Today we talk about Rei fellowship programs and Rei fellows answering those two questions because they're not exactly the same question. The question of how you get more Rei fellows isn't necessarily the exact same question as how you create more fellowship programs. But we do talk about both of those questions. My guest is Dr. Rachel Weinerman. Dr. Weinerman did her fellowship at Penn. She's been at university hospitals in the Cleveland area since 2015. She's been their program director for the fellowship program there since 2021. And she's got some ideas. First, I kind of poke at her for a little bit. And I make us spend some time on this question that we've talked about a lot on this show, which is what does an REI need to be doing versus what does the IVF specialist need to be doing? Because very often, we approach that question from the other way, the way we usually approach that question is how much Rei training does an IVF specialist need to have? So I tried to take that question from the other way. And I made us spend some time on it even though it isn't the main topic of this episode, because I wanted to try to isolate how important is the scarcity of REI fellows? If the volume question isn't at play, if technology solves for a big chunk of the volume question is the lack of Rei is still a problem. I wanted to isolate that and I think we did successfully then we started to get into the steps of setting up an REI fellowship starting with the roles what's a Boggs role, what's ACGME his role, we talked about ACGME rules. We talked about Medicare rules, we talked about what Medicare pays for not a lot. And then we talked about what the institution pays for. And that got us in more to the costs of running an REI fellowship program, the irei salary, their insurance, their mail, practice their benefits, paying for program coordinators, paying for other conferences, training capacitation and other professional development. Finally, we talked about who's going to pay for all this and what are some ideas ideas, including allow Rei fellows to perform those services for which they can build up to the capacity for which they're allowed to build national organizations like ASRM and Sri possibly contributing to a fund and things those national organizations can do beyond just funding like standardizing a didactic curriculum suggested rotations and we talk about this trend of private Demick partnerships, but also their limitations. Why have we only seen some of them and not an explosion of everyone doing them? Everyone seems to agree that we don't have enough Rei is coming out of fellowship, regardless of where they stand on how much Rei training they think IVF specialists need. I've never had anyone argue the opposite, that we have too many Rei fellows or that we don't need more if you do have that viewpoint, you're welcome on the show. But this is a problem that everyone seems to have consensus from that I can tell. And so I hope you enjoy Dr. Weinerman's insights on why this is happening and what we can do. Dr. Weinerman, Rachel, welcome to Inside reproductive health. Thank you. It's a pleasure to be here. You were a profile of person that I wanted to get to know that I am glad I've gotten to know this year because I really am interested in how the REI fellowship works, how we get more of them. What's necessary what's not necessary because I'm not a clinician I can't get I don't have a dog in this fight of that we should be training OBGYN to do A and Rei is don't need to be doing B I can't really opine. I can only facilitate the conversation and try to pull in as many points of view as I can. You are a bit more qualified to opine. And so I want to start with just let's start with the importance. What are the important things in your view that REI has learned in fellowship that can only be learned in Rei fellowship? 


Dr. Rachel Weinerman  04:05

Yeah, great question. And thank you for having me on the show. I want to start by saying that my opinions that I express are my own. I'm not representing any official organization within the world of Rei. I am program director. So that makes me I hope qualified to discuss this topic, but I'm really sharing my own opinions. So first of all, let's think about what is the history of REI training. So Rei fellowship has existed since the 1970s. When these evolved and adapted, you know, in 1974, when the first board exam was given in Rei IVF didn't exist. So what we've done in training our REI has obviously evolved in the last 40 plus years. So where are we now in 2023. We have comprehensive training programs that train OB GYN who are already fully trained obyns. To become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and fertility positions. This is very different than training an IVF physician. Because what we're trying to accomplish in an REI fellowship is to train subspecialty physicians who are experts in reproduction, who can serve as consultants to general OBGYN and other physicians, and who can provide comprehensive clinical care and infertility and other reproductive disorders, as well as innovate and move the field forward. So that we are constantly improving our knowledge and what we can do for our patients started. That's the overview of how we frame our fellowship training. And I think that really informs what we do in a fellowship. 


Griffin Jones  05:48

So how much of a rabbit hole do I want to go down? Now? I guess I will touch it a little bit that where someone who is doing IVF doesn't necessarily need to be in Rei, are you simply making the distinction that Rei is a lot more involved than just IVF? 


Dr. Rachel Weinerman  06:03

I would say the latter. I think that currently the way that we structure IVF practice in this country, and we can discuss whether that's going to change the future or not, in order to practice IVF, with the full depth of the field, you have to be trained as an RBI physician, and ri physician doesn't just do IVF. But the knowledge that you get the depth of experience that you get informs your ability to provide proper care in IVF. To put it up maybe a little bit more specifically, the way that I train my fellows. I want them to be able to be creative, and how they provide IVs care, I really don't want them to practice algorithmic medicine. And in order to do that, you have to understand the basic physiology, you have to understand what's happening at a molecular and cellular level, in order to make decisions that best account for the information that you're getting in real time.


Griffin Jones  07:03

 Is that at odds with an operational scaling system, I had one guest, a CEO from a fertility network in India that that that episode will almost certainly have aired before this one does. And he was speaking about their network has one set of protocols, there's one protocol per patient profile, and they have 250 physicians. Now there isn't an REI fellowship in India. So these are OBGYN physicians, but they have 250 in their network, and they're all practicing from one set of protocols. And I said, I have worked with two Doctor Rei groups in the US that have different sets of protocols. And so is what you're saying where you don't want your Rei is necessarily practicing algorithmic medicine. Is that odd with a scale of operations of something like having one set of protocols?


Dr. Rachel Weinerman  08:05

That's an excellent question. And I think this gets to one of the biggest questions within medicine is do you practice based on what we call standards or algorithms? Or do you practice based on individualization? And I think that in America, we have excellent outcomes. And IBM, obviously, they couldn't always get better. And what accounts for our excellence? Well, there's many, I would say many things. But I think one of them is our ability to provide high quality of individualized care. Now, that's different, right? In large practices versus smaller practices. And you might say that large practices do have more of a focus on standardization, which is another word for algorithm. But when you have physicians that have that in depth training, they can pin it. So the way that I tell my fellows is, you can do the first cycle as an algorithm. Right, but in that first cycle is successful. Great. But if that first cycle is not successful, what's going to be your next step? How are you going to pivot and change your treatment plan to account for what happened in that cycle? And that that's very difficult to create algorithms that account for each situation that you might encounter.


Griffin Jones  09:14

So that's on the side of, of how much RTI training should IVF specialists be able to have or at least be involved in? How much else should RBIs be doing beyond? IVF? So I'm thinking of the question this wave, when we have David Stabler and a number of others, I will say we're doing about 200 250,000 IVF cycles in the US we need to be doing somewhere around 2 million perhaps more than that. And, and so that is to suggest that we need more IVF being done, but if there are other ways of being able to scale IVF what else should RBIs be doing beyond IVF?


Dr. Rachel Weinerman  09:59

That is Excellent question. I don't think I have all of the answers to the scalability question, because I think that that might entail a significant reimagining of how we provide care. So I think that's an excellent question. I don't think I have a very specific answer to it. Because I think it's a really philosophical debate about how do you provide infertility services and IVF. Specifically, what a reproductive endocrinologist is trained to do, and we were able to do after fellowship is provide comprehensive care. So that means that if a woman comes with irregular periods, with abnormal reproductive hormones, with fibroids with malaria, and abnormalities, all of those can be addressed in a way that allows her to proceed with her reproductive goals. So that is what every doctor of endocrinologist can do. Can that be broken up from IVF? Again, I don't know the answer to that question specifically, but you can't provide full comprehensive infertility care without those additional areas.


Griffin Jones  11:05

What distinguishes our AI train doctors from other physicians in the field of infertility?


Dr. Rachel Weinerman  11:14

Yeah, great question. So I'm going to assume that what you mean by other infertility physicians are OBGYN,


Griffin Jones  11:21

OBGYNs are, yeah, almost almost certainly OB GYN 's or I guess, advanced practice providers working with OB GYN.


Dr. Rachel Weinerman  11:28

Right. So those are two different categories. So advanced practice providers typically have two years of schooling, after college, and then they don't have any formal clinical training after they graduate their program. So a lot of knowledge gained by advanced practice providers is going to be in the clinical setting on the job, what you might think of as an apprenticeship. And they are trained for the clinical work that they'll be doing, but specifically by who they're working with. So that might their practice styles may change. And then the depth of knowledge that they have is obviously different. And OB GYN will have completed four years of medical school and a four year residency in OB GYN and they they have you know, significant more depth of knowledge, their experience in Rei specifically, may be more limited. Most OB GYN residencies require at least a month of REI training, but sometimes it's only a month. So that's, you know, they obviously have that expertise in many areas with an OBGYN, but they may not have that depth of knowledge to be able to practice infertility and a lot of that learning that would require that would be necessary if they were to practice infertility would have to come after training,


Griffin Jones  12:37

I'm thinking there's a few Fertility Center practice owners that I can think of that were sort of grandfathered in prior to fellowship requirements that never had an REI fellowship. And then there are others that I can think of that work in fertility practices they work with and under an REI in many cases in they have for years, but they never had a fellowship. And and so I don't believe that they're board certified because you need you need the fellowship in order to take the boards, right. You can't.


Dr. Rachel Weinerman  13:07

Yeah, so I can go over that in more detail for you.  Yeah, this question of okay, you have some Doc's that were grandfathered in. And you have other Doc's that maybe they weren't grandfathered in. They're still working with REIs, but they've been doing it for 15 years. And so what does an REI fellow What does someone gain in Rei fellowship that they might not have gained? Well, first of all, is a great question. We do have doctors who are grandfathered in, I would say many of them are older, you know, pre board certification for i o that that is tend to be phased out. You know, 15 years is a lot of experience. I would say a lot of OB GYN working now may not have that length of experience going into an infertility practice. But let's talk for a minute about what Rei fellows do do and fellowship. Currently, fellowship is three years in the past used to be two years, there's some discussion about whether that link should change. Fellows are they do at least 18 months of clinical rotations, that includes training in infertility and what we call a RT, not just IVF. They do surgery. They do genetics, they do male infertility, endocrinology, pediatric endocrinology, and increasingly spending time in the IVF laboratory learning IVF techniques, then they spend at least 12 months doing research. And that research culminates in a thesis called a scholarly thesis that has to be presented. And it represents a significant scientific effort, which demonstrates knowledge not only of the scientific literature on the scientific method, but how to critically appraise what is happening in the world of scientific knowledge and Rei, and how did you innovate in that field that demonstrated by doing that type of project, and then they typically also have six months of electives, which can be individualized to the fellow and their and their training requirements. So that's The overview of what they do in order to then actually practice within the field of REI, they have to take a an exam from the American Board of Obstetrics and Gynecology, it's actually two, they take a written exam called the qualifying exam. And then they take an oral exam, which is the certifying exam. after they graduate, they collect cases for 12 months, and submit their case list along with their thesis in order to sit for the exam. And then they take the exam, which is a three hour oral exam.  So there is a breath that people are learning in the REI fellowship program. And that takes me back to the question of what else should always be doing and I thought of a different way of asking the question. So if we're doing 250,000, IVF cycles or so we should be with 1200 RBIs. And plus probably some others, because that almost certainly includes OBGYN who are part of that process. But let's just say we've got 1200 RBIs in in the country right now doing 250,000 cycles. If with technology with training other Doc's and other positions, massive operational improvements in the next 10 years, we are doing 2 million IVF cycles from 1200, RBIs, or even fewer. What I'm saying is right now a lot of the argument for increasing the number our very eyes is because we need to to meet the demand, let's just pretend that we can meet the demand with with the improvements that happen over the next 10 years. Do we still need more REIs, then if we're if we're seeing if we can meet the IVF demand? Do we still need more areas? And if so, what for? So I would I would answer with a resounding yes. I think we need more. And I think what I'm when I'm describing about Rei fellowship, and the intensity of fellowship and the value of fellowship, doesn't change the fact that we don't have enough REIs. And we can talk a little bit about some of those impediments. Why we don't have as many Ira fellowships as we do, how do we train more Rei fellows. In the end, in order to practice quality medicine, you need more REIs, even if those Rei are supervising they advanced practice providers or other physicians that may not have Rei specialty training, in order to scale up as significantly as you're describing, you would still need more REIs in those roles, they may not be always providing the direct care, like they may be supervising other providers. And I would say that that's an appropriate role. But if you don't have an REI involved in that supervision, then likely the quality of care will not be what we want it to be. And the innovations won't occur.


Griffin Jones  17:41

Is there anything else beyond supervising IV? Is there more research that needs to be done? Is there more? Are there other areas of medicine that era is should start to be? I guess I don't know what the word would be cross discipline with is beyond supervising to meet that scale? What other responsibilities should the REI take on if AI and all of these other technologies and systems do in fact, and I understand it's a big caveat. But Fiat that may for a moment, and what else should they be doing?


Dr. Rachel Weinerman  18:15

So let me put it this way. There's a debate within the world of REI as to how much that II shouldn't be there. Right. Rei is reproductive endocrinology and infertility. How much should the REI focus be on endocrinology. That's historically what the field was, again before IVF existed, you know a large role that that the RBI had was in managing hormones. Now we still do. But that looks different now that we have AR t as a huge component of what we do. So should that E be replaced with for example, a G for genetics, a lot of what we do now is involves very complex genetic information, both from the perspective of the patient and the patient's partner, and from the perspective of the embryo. And the information that we're getting is, is enormous, it's complex, and it's changing. So to be able to adapt to care for patients in this changing environment, that is an area of focus that Rei might consider in the future. The other question is gynecologic surgery. And that historically has been a very important part of what Rei is do and is still a very important need. There are many patients whose fertility needs cannot be solved with AR T alone. They need surgery in order to be able to accomplish a successful pregnancy. And that historically has been the role of Rei. There are now more widely invasive surgeons within the world of GYN who do some of that surgery. That I would say is an open debate. There's many different opinions. I personally work at an institution that is very surgical heavy, and we are able to provide that type of comprehensive care for our patients. So let's say what else could REI be doing? I would say those are two areas that I would say we have to think about how much we want REI involvement. And then I would say what you mentioned about research is extremely important. I use the word innovation before. And I think that, to me, research is a prerequisite for innovation. If you don't have people trained in being able to perform research, and assimilating all of these types of complex data, you will not see innovation in the future, you will not see improvements in pregnancy rates, you will not see improvements in the what we are able to provide, I don't know what IVF is going to look like 40 years from now, I hope it looks very different than what we're doing. Now, I always tell my patients, you know, I have to give them the option of donor egg, for example, now, because they don't have, you know, any egg reserves to be able to get successful autologous IVF, I hope that's different, you know, by the time I retire.


Griffin Jones  20:57

the reason I kept poking at that is because I said, this kind of Nexus where there's a lot of venture capitalists and private equity people, as well as fertility practice owners and doctors. And so and and see them come together, and I see them having conversations, a part of one of the conversations that is coming from the doctor, and is well, what do we do if AI is really able to scale us up to this level? If, if other doctors are able to do these procedures, if we're able to use technology and systems to answer a big chunk of the volume question, then what is it else that we do? And and so where your mind went with that is, is the answer that I've been looking for it to that is because there's going to be something for you all, I try to tell the REIs don't freak out, it's just going to be, it's going to be different, I think you're going to be doing just fine, no matter what happens, but I think it will be very different to 10 or 20 years from now. And I'm neither a clinician nor a futurist. So I have to pull it out of I have to make people like you speculate in order to try to paint a picture, in that you started to talk a little bit about why we don't have enough programs. And I in my view, I'd say we we don't have enough. We recently inside reproductive health wrote an article, the journalist interviewed you. She also pulled up some numbers on the number of programs. And I think the according to the National Resident Matching Program, there were 49 Open fellowship positions in 2022. And I want to say that was like from 41 rei fellowship programs, according to that same that that same national Resident Matching Program, so why isn't enough? Why isn't it enough? Why don't we have more?


Dr. Rachel Weinerman  22:42

Excellent question. I don't think I have all the answers. Do you know why? Why don't we have more, but I can begin to explain from our perspective now. Maybe you know what some of those answers are? I would say that the answer your first question is we do not have enough. And I think that is that is a consensus, I would say among most RBIs we need to be training more fellows to be able to provide high quality, fertility services and our guy services in the future. Why don't we have enough? So let's start with a little bit about how Fellowships are structured, who pays for them? And I think that might answer some of the questions. So first of all, infertility Fellowships are under the rubric of what's called the ACGME, the Accreditation Council for Graduate Medical Education, and a bog, which is the American Board of Obstetrics and Gynecology. So with our long names, but essentially ACGME accredits programs, you know, allows them to function and then fellows are certified by a bar. So those are the two organizations that are in charge. In order to be an ACGME approved fellowship. There are a lot of requirements. In fact, there are I just looked at the program requirements before our session today, there is a 56 page document of everything that a program has to do to have a Rei fellowship. That includes being under the rubric of a sponsoring institution that has an OBGYN residency. So you can't have a fellowship without being embedded in an OB GYN residency, which is essentially most likely either an academic institution or a large institution that can sponsor that. And you need to have a program director who has dedicated time program coordinators who have dedicated time you have to have ancillary services in many other specialties. Medical endocrinology, pediatric endocrinology, genetics, male infertility, full operating room, full hospital privileges, access to the medical literature, I mean, the list goes on. So you can imagine that this is not an easy thing for lots of institutions to do. And it takes about two years to get a fellowship up and running. And then the second question that I I alluded to was, who pays for this? Because it's expensive to run an REI fellowship fellows typically costs somewhere between 100 and $150,000 a year. Some of that money comes from Medicare, actually, Medicare pays through direct and indirect funding to hospitals. But the number of fellows or residents that can be paid for through Medicare is actually capped. And those numbers are capped based on 1997 Trainee levels. So it's very difficult to get funding from Medicare for a new fellowship. And so often, that funding comes from the sponsoring institution, whether it's the hospital or or practice. And it makes it challenging because fellows actually can't bill for their time. So your training fellow, but that fellow is not going to make you money in the short term, because fellows have to be supervised, and you can only really bill for the time spent by the attending physician. So they're not making you money, you're spending money on them. It's an investment, but it's not an investment that everyone can do. So I'd say the combination of the logistics of running a program and getting it off the ground, the requirements, which are significant in terms of what the ACGME asked for in a program, and then how to pay for fellowships are some of the contributing factors. 


Griffin Jones  26:12

And when you say it's an investment to train fellow fellows when they can't build for time, it's an investment but very often it's an investment for someone else, isn't it? Right? You are you're the one training them but in many cases, they're gonna go work for someone else, you're gonna go move to whatever part of the country they want it to go to, or people do stay where they went to fellowship sometimes and there is perhaps an increase happening. I don't as we see more of the of the private academic partnerships, but of people staying at least within that organization, maybe I suspect that there is is the limitation in not being able to have more private partnerships that the reason I asked is because when you say that they have to, you know, they have to have an OBGYN residency well, almost every teaching hospital does now I am I you know, I think at the University of Buffalo I think of places like Stony Brook Binghamton and University of Arizona, Arizona state. They all have medical schools and and OBGYN residency. So I believe almost every place that that does, that has a teaching hospital has an OBGYN residency program. Right. So it seems like there's still a whole there's still a whole pool in that group that could qualify. Is it that people that don't have that partnership with an academic institution that can't bring on a fellowship program for that reason? Is that the limitation?


Dr. Rachel Weinerman  27:42

It's one of them. So yes, there are many OB GYN programs out there that do not have attached ROI scholarships. I mean, right. There's only 49 fellowships, there's a lot more OB GYN residency. But if you are a very high volume, private practice, and you you think, hey, I need more Cielos let me open up my own fellowship so that I can train fellows, have them stay on hopefully, in my practice and build my practice that way, you then have to seek out an institution that has an OBGYN residency to partner with, in order to accomplish that,


Griffin Jones  28:15

how much infrastructure is required for that? Because I can think of smaller practices, maybe two to four RBIs that are in the backyards of a lot of these, these hospital systems or medical school, they do have OBGYN residencies, why can't they it seems to just be right now be the larger institution. Can you talk to us a little bit more about what else would go into the infrastructure that would stop a smaller practice group from linking up with a hospital system?


Dr. Rachel Weinerman  28:43

Well, I think that if you have willing partners, you can do it. I don't think that there's a lot of hurdles necessarily to a smaller practice looking at what the bigger hospital system, if there's a willingness on both sides, you know, the hospital then may want their residents to rotate with that practice. And by the way, every OBGYN residency program has to have a relationship with an infertility or Rei division, because it is a requirement of their OB joining residents to rotate on Rei. So I'd say most OBGYN residency programs do have a relationship in some form, with an REI program, you know, either whether it be IVF or an academic Rei division. So I don't know that that's necessarily the hurdle. I think the hurdle is that it takes time to to train fellows, it takes time to set up the fellowship, it takes time to run the fellowship. And there's not a lot of financial incentive for that practice to to pay for that fellowship, unless they know that they are going to be successful in recruiting and retaining their fellows. And in the past, you know, that was actually I would say a negative right people didn't want to retain fellows there was not a not enough spots. They didn't want to train their competition. Now obviously, we're in a slightly different, significantly different situation. So maybe we just need to catch up to that. But I think that the amount of time and the amount of money invested is an impediment to small practices, who may not be able to devote those resources.


Griffin Jones  30:10

Do you think I'm making you think on the spot because I'm just hatching this idea in my brain right now. But the debate that goes back and forth about how much OB GYN should be allowed to do versus how much RBI should be able to do if you were allowed to bill for fellows because OBGYN 's were allowed to do, and there's certain parts of the procedure or they were allowed to bill at the same rate, or I'm, that's beyond my paygrade of the knowledge that I have in that area. But if that were, if it were the case that OB GYN 's were able to build more at what our eyes are able to maybe they are already, but if that were the case, would that then allow for fellowship programs to bill for Rei fellows, has that ever been discussed? And might not thinking of something else? Is there something unethical in there that I'm missing? 


Dr. Rachel Weinerman  31:06

So great question. And no, it is not unreasonable to think about, in fact, one of the challenges that we have now within REI fellowships is we have to think creatively about how to get more fellows thoughts out the most fellowships in the country probably have the capacity to train more fellows, and they're currently training. So I know that's true. In my fellowship, I trained one fellows a year, I could easily train two fellows a year, you know, double the number of fellows that I'm training, I could probably even train more than that, you know, based on the volume that we do in both Rei work IVF work and surgery. The main reason I can't Well, there's two, one, you have to get approval from the ACGME. But assuming that you can do that, it's the it's the funding, how do you pay for those extra fellows? So that's something that we are, everyone I think is thinking about that now I'm thinking about it, there is one slight impediment to what you're discussing, which is the regulations that govern what an ACGME approved fellow can do. So within an OB GYN fellowship, like REI, cellos, can bill independently for four hours a week and their primary specialty. So a fellow could do GYN clinic, pap smears, you know, irregular bleeding, anything that is restricted or not part of REI training, they can do for four hours a week. And so there, I think that is an idea is to have fellows Bill independently during that time, and then not be enough actually to pay at least part of a salary salary for all of our fellow sellers. So I would say that yes, that is a that is a good idea. There are some limitations to it. But if done well, in a way that is respectful of what the fellow is there to do, which is to be trained, that that might be a way to allow more fellowships to have additional fellows or to allow new fellowships to start


Griffin Jones  32:54

that up to four weeks in the specialty that they are already board certified in, that they're allowed to bill for? Is that too much of a distraction to their current fellowship? Would that take them away from what they're supposed to be training for in the first place?


Dr. Rachel Weinerman  33:10

Right, so So four hours per week, just to be just to be clear on that. It's what the ACGME specifies. Now, I mean, that's, I guess, a philosophical question. Personally, I think that if, if you're allowing more OB GYN to train as Rei Sallows, I think that half a day a week is reasonable. So I think it probably would not detract significantly from the fellowship, and I think it would allow more fellows to be trained. So I think that's, that is an idea that, you know, I'm thinking about incorporating into my own fellowship.


Griffin Jones  33:40

So it's ACGME that makes the ruling that fellows are not able to bill for the subspecialty that they're training for is that


Dr. Rachel Weinerman  33:50

it's actually it's it's Medicare rules. So because Medicare is paying for, for resident and fellows, we called trainees then they can set guidelines in terms of what fellows can and residents can build.


Griffin Jones  34:04

And this is true for all fellowships as gufram I found this is true for fellowships outside of OBGYN is


Dr. Rachel Weinerman  34:10

correct. This is true for all residents and fellows in the country that are under the auspices of ACGME. Now, what ACGME specifies for Rei specifically, is how many hours an REI fellow can work in OB GYN, what they call their primary specialty.


Griffin Jones  34:26

So I've never actually compared the lack of fellowships and our view to that of other fields is every subspecialty or almost every subspecialty having an issue where they feel that they're not able to produce enough fellowship programs or trained enough fellows per fellowship program or as this how unique is this to REI?


Dr. Rachel Weinerman  34:48

I think it is somewhat unique to REI, and there are you know, most other specialties outside of OB GYN have larger fellowships, you know they might train five fellows a year eight bells a year are fellowships were set up in the beginning, almost more like apprenticeships and so having one fallow became the norm. You know, for each program, it was not necessarily the case for other fellowships outside of OB GYN within OB GYN. It is it is more similar in the sense that most OB GYN fellowships don't have more than one or two, maybe three per year at most institutions. But the number of MSN fellowships, GYN oncology fellowships, female pelvic medicine, fellowships, have all increased much more significantly than the number of REI fellowships.


Griffin Jones  35:35

The reason I asked is because perhaps if this was more endemic to all fellowships, then there would be more likelihood of perhaps Medicare adapting rules set, maybe you could bill partially for whatever it might be, but it's less likely to see any type of change from Medicare, if it's just the field of REI, or only a handful of fields that are having this challenge. So can you talk to us a little bit about the specific costs and probably by the time this episode airs, we we will have aired a or we will have ran another article where the same journalist did it follow up follow up to the to the first article talking about setting up Rei fellowship programs. And it was very difficult for the journalists to to button down some costs. And we had some quotes from your colleagues to talk about a little bit of what goes in to the variables of those costs. But try to walk us through that as best you can. Variables be damned.


Dr. Rachel Weinerman  36:33

Right. So I would say first of all fellows, you know, they don't make a huge salary, you know, especially given the level of training, what they could be making, if they were, you know, at working in independent practice after they graduate from an OBGYN residency program. But typical fellows salaries, probably somewhere around $75,000 a year. So that's a direct costs, then you have the cost of benefits, you know, health insurance malpractice, which is paid for by the institution, you have costs associated with the program, for example, you know, paying for the program directors time and the program coordinators time, there are resources that you need in order to have that program such as access to the medical literature. So if you're in a big institution, academic institution, which you know, a lot of programs are, then that's not necessarily a problem. But if you're in a smaller institution, that might be at an additional costs. And then you have the cost of a fellow education. So you, you know, you are paying for fellows to go to conferences, you may be paying for your fellows to get a master's degree in clinical research or translational research or public health that you know, includes tuition. And then you are also paying for additional educational resources for your fellow. So obviously, that's how the costs can add up to, you know, over $100,000.


Griffin Jones  37:50

And so, in, in your view, what do we need to do in order to be it are the things that can be done right now to get more fellowships? Online? Does it all lie with the institution having to figure out a way to pay for it? Are there other things that we can do right now to get more fellowships online?


Dr. Rachel Weinerman  38:13

Yeah, great question. So I would say, again, this is my personal opinion, but I think that in order to get more fellows, right, which is different than more fellowships, I think that we need to think creatively about how to pay for fellowship. And I think that one of the, we talked about one of the ideas, you know, having sponsorships by you know, national infertility organizations or private organizations, to fund individual fellows or individual fellowships would also be, you know, a great way to immediately get more fellows how to get more fellowships, is to lower the hurdle for entry. Now, that has to be done in a very conscientious way. Because if you're lowering the hurdle, you know, significantly, everything that we talked about, for why Rei fellows are trained in a way that is unique and important for the field are not going to exist. So you have to lower the hurdle in a way that maintains the quality of the education. And that can be done by you know, for example, saying that we are going to provide resources for program directors to you know, maybe have a way of submitting their application without spending hours of their time reinventing the wheel. It might need, you know, lowering the the administrative burden, which the ACGME is already already working on. It could also mean providing standardized resources from national organizations that can be almost like a toolkit. Here's how you start an REI fellowship. Here's a didactic curriculum. You know, here are some common rotation goals. So that way someone can say, okay, great. I want to start an IRA fellowship. Here's how I do it. I think that that's a big challenge right now. And I think that making a more systematized way that we can provide support for organizations to start a fellowship, in addition to financial resources, I think would be very important. And we could do that soon. We could do that and probably increase the number of fellows immediately fellowship, like I said, takes about two years once you apply in order to actually see that come to life,


Griffin Jones  40:18

when you mention national organizations, are you referring to the ASRM? SREI, Who who are you referring to?


Dr. Rachel Weinerman  40:26

I would say those are, those are prime examples of who could provide that oversight. SREI is a national organization that provides oversight for the fellows. So I think SREI is a great organization that can help with some of these proposals that I'm suggesting, which are more, you know, a more standardized approach to starting a fellowship or the resources to run the fellowship.


Griffin Jones  40:47

And so when you say, so if they were to include if they were to help pay for some of these resources and pay for more fellows to come in? Many of those organizations get some of their funding from sponsors. Is there any kind of legal framework that you're aware of that would prohibit let's say, ASRM starting a larger fund for to contribute to more fellowship programs, if it was funded by pharmaceutical companies or genetic testing companies or, or others? Is there anything that prohibits that?


Dr. Rachel Weinerman  41:21

Not to my knowledge, but I'm not an expert in that area? So I would probably defer to somebody from a theorem or Sri to answer that question.


Griffin Jones  41:28

I'll save that question for next time. I have Dr. Robbins on the show as the first first question he's getting ambushed with next time. So and when you talk about having more fellows per fellowship program, you said you could easily do two a year perhaps even more than that. You said that ACGME first needs to approve that how how hard is that is the only reason why people aren't doing more of that right now, because of the cost or are there other hurdles that AC ACGME puts forth? Other than cost to say, No, you can only have one fellow per year?


Dr. Rachel Weinerman  42:07

Yeah, I would say both, I would say probably the main impediment is, but there are significant challenges to trying to increase the we call the complement of fellows. The ACGME wants you to demonstrate that you have sufficient clinical resources and research infrastructure to train that additional fellow men, sometimes they can be picky. So you may think that you have the capacity to train additional fellows, the ACGME might not agree. So I think that is that is a challenge for some fellowships. You know, that's something that we could advocate for, you know, within the field of REI, but I would say that that that probably the answer is both.


Griffin Jones  42:41

Well, you've walked us through quite a bit about how fellowship program gets off the ground, what we could do to get more Rei fellows and more Rei fellowship programs, viewing them as part of the same problem, but two different questions. How would you like to conclude on this issue?


Dr. Rachel Weinerman  43:00

I would say that you're asking an excellent question at a very relevant, I think we are at a crossroads in the field of our AI, we know that the demand for what we will be doing is going to be increasing exponentially. We know that there are challenges that come with that type of growth. And we know that there are going to be many different changes both in terms of technology and in terms of who provides care. I think at the heart, being an REI physician means that you have significant understanding of the reproductive system, and are able to implement changes in innovation and how they provide infertility services. I don't think the role of the REI is ever going to go away. I think that we just need to work very creatively to expand the number of fellows that we're training without sacrificing that level of training, and incorporate Rei trained physicians into a larger team in order to provide excellent care for our patients and hopefully adapt to the needs of the future.


Griffin Jones  44:02

Dr. Rachel winderman REI Fellowship Program Director at University Hospitals, thank you very much for coming on inside reproductive health.


Dr. Rachel Weinerman  44:09

Thank you so much. It's been a pleasure being here.


Sponsor  44:12

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

184 Mastering Efficiency in the IVF Lab: Strategies and Insights with Dr. Liesl Nel-Themaat


Are you seeking ways to enhance the efficiency of your IVF lab and improve patient outcomes? We invite you to listen to the latest episode of Inside Reproductive Health, where host Griffin Jones engaged with Dr. Liesl Nel-Themaat, IVF Lab Director and Associate Clinical Professor at Stanford University.

Here are some key takeaways:

  • Identifying and addressing common inefficiencies in the IVF lab.

  • The importance of standardization and its impact on success rates.

  • Strategies for optimizing workflow and reducing turnaround times.

  • The role of technology in enhancing lab efficiency and patient care.

  • Overcoming resistance to change and implementing effective process improvements.

  • Best practices and practical tips for managing patient flow and scheduling.

Stanford Fertility and Reproductive Health
Dr. Liesl Nel-Themaat’s LinkedIn

Transcript

Dr. Liesl Nel-Themaat  00:00

You don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that.

Griffin Jones  00:24

Ask 23, IVF, lab directors and embryologist. What the biggest inefficiency in the IVF lab is and get 23 different answers that was part of the talk that my guest a vet PCRs Her name is Dr. Liesl nelta Ma. She's the lab director at Stanford's IVF lab. She has been an embryologist and lab director at different labs throughout the country over the last 20 years. And her model was about the inefficiency or talk was about the inefficiencies in the IVF lab. And I started the conversation off equating that with automation, we sort of got into a little bit of a semantic discussion, I hopefully still wasn't thinking that I perceived her as being anti automation. But I also didn't think it was entirely semantics, she was painting something for me where I could see that it's not just automating things in the IVF lab that is going to make it more efficient that you could automate quite a bit in the IVF. Lab. And you'd still have inefficiencies in different areas. So she made that clear to me. And it's I'm also on this cake that you hear me talk about with David sable a lot about when does it just make sense to replace a model entirely? You know, we could have made faster cars, but eventually you come up with something that replaces that entirely with aviation, for example, when does the existing IVF model just become marginal at best with the improvements, you can make an efficiency versus scrapping it and starting with something all together? And so I was having that like, philosophical question in my mind while she was thinking of the particular inefficiencies that she was isolating. So hopefully, that didn't mean she didn't feel like I thought she was anti automation. I certainly didn't. But I moved on past that part of the conversation for your sake inside reproductive health listener. And we got into specific examples talking about plastic where how that became worse. During the COVID pandemic, we talk about paperwork and what paperwork could be automated. We talk about those times sets or inefficiencies in the IVF lab that should be eliminated altogether, because you should never delegate something that should be automated. It also should never automated something that could be eliminated altogether. Then I made the sole say what she thinks is the biggest inefficiency in the IVF lab and extend that to globally as opposed to being in the IVF lab because in her view, it's something that affects the IVF lab is related to the IVF lab, but isn't coming from the IVF lab after this episode. I would love it if you email me or comment on any of the social media platforms that you came across the episode on what you think the biggest inefficiency is, if you think we missed anything. I would love your opinions of what you think are the biggest inefficiencies in the IVF lab. But right now enjoy it from the viewpoint of my guest, Dr. Liesl Melton on Dr. nelta mod, Liesl, welcome to Inside reproductive health.

Dr. Liesl Nel-Themaat  03:40

Thank you very much. I'm thrilled to be here.

Griffin Jones  03:43

I became aware of you at PCRs you are giving a talk about automation in the IVF lab or maybe about the lack of automation happening in the IVF Lab is a very comical talk, you involved a lot of people, you had a couple of different things in your giving examples of things that are all, you know, antiquated in the lab that could should be automated should be improved. At least I want to go into those examples today. But maybe let's start with just a synopsis of what was your talk about and what were you seeking to educate the audience about?

Dr. Liesl Nel-Themaat  04:19

Well, in essence, actually, it was not pushing towards automation. More what I was going for is the base back to the basic lab efficiency. So a lot of times these days people are getting excited about the automation, the new technologies, robotics, fluidics AI, things that make very cool presentations. But what I was trying to more convey to the audience is that the vast majority of labs are still working with basic things, basic skills, basic supplies. In the lab, and there is a huge opportunity to make things much more efficient. If you just look at the things that you already have and work with, you don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that. Automation would be a completely the next step. You know, if you want, I think there's a lot you can do before the automation,

Griffin Jones  05:38

I want to make sure I understand this difference. So what would a couple of examples be of just those basic skills or supplies that could be made more efficient?

Dr. Liesl Nel-Themaat  05:46

One big example, go to your staffing model. For example, in my talk, I talked about all these different types of personality get in the standard IVF lab, and that is heavily influenced by the size of your program. So the more IVF cycles you perform, the more people you need in the lab and a basic small program, maybe would have five embryologist and maybe two juniors maybe to seniors and a lab director. But then at the as this practice grow, are you going to one of these larger networks where you have a hub and spoke model, you might end up with, like 20 Different people in your lap. And it's the range from on site lab director, there's managers, supervisors, team leads, seniors, juniors assistants, shipping coordinator per DNS. And all of these different roles have different costs associated to it when it comes to your staffing model, right. And I shown in my presentation, just by adjusting how you put your team together, you can have enormous savings, and bring down your lab expense significantly, just by being wise with how you build your staffing model. So that's one example. You don't need any technology for that. Right.

Griffin Jones  07:03

So what maybe we'll get into a conversation about it, if that's necessary because of automation. But first, let's dig into those examples a little bit if we've got a hub and smoke model with a need for 20 people in the lab, how do you restructure that team so that you don't need as many people are so that you're getting more out of each of them?

Dr. Liesl Nel-Themaat  07:27

So a classical example is, a lot of times, senior embryologist, you know, as a practice grows, they small practice have limited number of staff and they can do up to a certain number of, you know, cycles, same average is about 150 per embryologist starting with minimum of two. But then what happens sometimes is as this practice grows, we need another embryologist, we need another embryologist. But the reality is a lot of this stuff that embryologist have been useful these days is data entry, administrative tasks, filing paperwork, retrieving paperwork, shipping coordination, all these things that you really don't need a very expensive, senior embryologist to do. So by replacing some of your high high cost center neurologists by more specialized people, like a lab assistant or shipping coordinator, or even using some per diems for when crunch time comes, you can actually significant, reduce your overall, you know, expense on your staff, just by redistributing the tasks and the responsibilities.

Griffin Jones  08:37

So wouldn't the proponent of automation just say well, yeah, but you shouldn't be giving those tasks to even a more junior person, if you don't have to the if you could totally automate the data entry. For example, if you could totally automate the renewal of ordering of supplies, then why give that to any human being? Why not just to have that as a part of the system? So why is efficiency important if automation seeks to make the efficiencies that we would gain by restructuring, pale in comparison?

Dr. Liesl Nel-Themaat  09:12

So just to you know, if there was any misunderstanding, I'm not against automation at all right. But let's say my program, we decided, you know, what we're going to automate that How long do you think that will take for the companies whoever is working on automation to complete developing, tasting, getting approval, then bringing it to market? Implementing it like, Yes, great. If five years from now, I can eliminate four of my staff members by bringing some fencing automated automation unit into my lab. Right, but I have five years that I don't have it right now. vast majorities of labs are not automated right now. So what can I do until I did get that technology. Again, I'm not against bringing in technology, I'm just trying to make efficient what we have and what you can easily achieve right now, before these next big things come into the picture, you know,

Griffin Jones  10:14

so I guess it depends on which next big thing is here and how now they are actually now actually present and ready there. Because I'm guessing that concern that you have is, which is we can automate. But there are things that we can do right now to be more efficient. If I'm a salesperson for any one of these companies, I'm thinking you trying to be more efficient is the waste of time, you should replace it entirely with our solution, whatever if whatever that solution might be for a particular thing. I'm thinking of one example, where I was recently speaking with the venture capitalists behind this new solution, that closets to be able to build a lab that can do 500 cycles a year with five techs, and nothing more. And so if that is the case, then I guess where I'm struggling is, is how do you know if the process of making it more efficient is worth the squeeze whether rather than trying to eliminate and automate the process? And,

Dr. Liesl Nel-Themaat  11:22

again, I don't know why there's that idea that I'm against automation. I'm not trying to eliminate it.

Griffin Jones  11:28

I'm not I'm not starting any I'm not starting any rumors on on this pocket? No, I know that you're not I'm asking because I'm thinking I'm trying to make the MCAT that calculus because I imagine that many of your peers are thinking, say, Well, should we do something or not? And I don't know what that what that calculus is for deciding, okay, we should try to just restructure and spend some time trying to restructure or we should seek a different solution. And how you approach that I

Dr. Liesl Nel-Themaat  11:58

think you should do both. I don't think it's one or the other, I think and even if you get your automation, there's still going to be places that the automation is not really touching, that you can still be more efficient paper usage. Let's talk about that. The amount of trees we are killing by doing paperwork and not going more electronic, you can have a machine that can automatically make your dishes it's not gonna resolve your your paperwork, wastage issue, right. Or you can restructure your staffing model, but it's not going to do anything for the plastic ware that you're using. So there's no one solution that's going to touch all the different areas that you can make more efficient. Like I played video, where I had asked multiple experts across the industry, what is the biggest lab inefficiency, not two people gave me the same answer. And that's the point I'm trying to make is yes, there are big ticket items that we could bring in new technologies. But there are so many places where you can be more efficient can save money for your organization can make your processes more streamlined and be friendlier to the environment. If you just conscientious and have this overall mission to be more efficient in everything you do, not just the one or two big ticket items that companies are trying to sell us right now,

Griffin Jones  13:27

as those examples that I want to make this conversation about, maybe we got bogged down in semantics for a second. But the you talked about paperwork as one of these examples. Why what's stopping the lab from being paperless right now, and what specifically should be paperless? And

Dr. Liesl Nel-Themaat  13:45

I think change is hard. I think everybody knows and use less paper and transition to all electronic and a lot of groups are moving towards that. But it is very difficult to make such a big change in a lab that you are used to I have my patient chart right here. This is where I document everything I do. It's first of all a big expense on the program. And then there's something about having a hard copy. And people just don't like change. It's difficult. I think we are definitely steadily moving towards it. But it's not something that you overnight going to be paperless than any practice right. So but you can make small steps towards it. And you can maybe double copy some of the things that you have at the moment still paperwork maybe the practice is not comfortable going completely paperless yet, but if you have the right mindset, you can move towards it or at least cut your paper usage in half like every time you print something Do I really need to print this is there a way I can have this electronically but doesn't interfere too much with my that workflow because there's always a balance, right?

Griffin Jones  15:02

Are there examples that you can think of, of things that shouldn't be printed almost categorically that, that that's just a waste

Dr. Liesl Nel-Themaat  15:10

consents, definitely. And I think COVID actually helped a lot with some of this where traditionally, patients would have signed paper copies of consents and get it notarized if they're not in the space, or gonna be able to come to the clinic. And I think COVID has forced the whole industry to become more electronic from telehealth visits to online consenting to, you know, explaining the treatment cycles, everything, instead of now giving paper handouts or welcome packets, and all that everything is done electronic. So we actually have COVID, to thank for some really good things that have come to our industry, I believe, the paper forms, I think sometimes there's a lot of duplicate things that might be recorded on forms where you could make it more concise, or just maybe have, if you if you're not comfortable going completely paperless, you can be wise about what has to be on a paper and what does not. So I think it depends on each practice, what kind of forms they do have, you know, when I was surveying a group of embryologist online and asking them, you know, how many pieces of papers was on average it 15 sheets? That would be things like, you know, your neurology worksheet and then you have your individual in row tracking sheets, you printing out your order, because you want it Do you really have to print out the order, you know, if that's electronic PGT worksheets that the company saying you print that out? Do you need to have a print out of that and your own PGT worksheet? You know, this, it really depends on every practice. But again, it's it's all about the mindset and the the, the vision and the mission to try to become more efficient. I'm sure every lab can go and look at the paperwork they use and identify at least one sheet of paper they can get rid of, you know,

Griffin Jones  17:02

can you give an example of where else it would go? Like, if you think back to the last five years or so where you were using paper? And some example it did it was? Was it something that changed to the EMR? Or was it something in a different type of workflow software? How did you eliminate paper?

Dr. Liesl Nel-Themaat  17:18

So we have not, we're still using a lot of paper, in fact, my my Kayla bow about six trees a year at the moment,

Griffin Jones  17:28

do they now listen to your talk? Yeah, you don't just you don't just sit them down and play the same talk for them.

Dr. Liesl Nel-Themaat  17:35

Now we started mentioning it, I haven't given this presentation to my whole clinic yet. But that gives you an example. So we have not but we started the conversation. Because when I had to find out how much does our whole clinic use, obviously our practice manager, I told her why wanted to know and say how, you know, we started the conversation, how much paper do you use? And now he's on the table. And then I say, Do you guys realize we kill six days a year? And now we're talking about it? So yes, I like I said paper consent to something, I think probably the majority of clinics I've gotten laid off, we still get copies in some instances. But we should not that that's the easiest for me to think of is that anything that can be electronic. And the good thing is this is not a form that we are generating on our end, when it gets difficult is when you have to do data entry. But you're not sitting at your computer while you're looking at, for example, embryo grading, right? I have I'm sitting at a microscope and looking at each embryo one at a time, and I have to write it down. And then I can take the computer and put it in my EMR. Now you could argue well, if you have the AI technologies with the live imaging, you don't have to do that, which is true, but most labs don't have that yet. Right. So can you get around that? Can you get comfortable enough that you might be can use the iPad instead of a piece of paper in real time while you're writing your embryos?

Griffin Jones  19:01

Oh, did COVID make plastic were more or less of a problem if it made paper less of a problem? What did it do with plastic where because you know where it didn't make plastic were any better? The whole effing rest of the world, you know, plastic everywhere. Now we have now everything's takeouts in styrofoam, it's in their individual wrap masks that all go everywhere. And so it seems like the plastic were got problem got worse in so many other areas of the economic sector. Was it better or worse after COVID

Dr. Liesl Nel-Themaat  19:40

classic where we've gotten much worse but for a different reason. It's because suddenly we have such big supply shortages because everyone was buying it at such a rate because they were worried we're going to run into supply shortages and then we created this superficial shortage or this this it wasn't real


Griffin Jones  20:00

Do you toilet paper and yourself? The IVF? The the IVF? Lab field toilet paper themselves said it.

Dr. Liesl Nel-Themaat  20:06

Yeah, you were listening to my talk. It's my cousin's analogy. You know, yes, we, it's not like suddenly all the labs, were doubling using dishes, they were just not available because big, people were just ordering more than they actually needed because they were worried they were gonna run out. And then we created this to a certain extent, artificial shortage of plastic where so people were scrambling, trying, you know, just to find get their hands on what ever plastic they wish they could find not necessarily getting the true and tested and, you know, validated plastic containers and dishes and stuff, but just, you know, open it up more for whatever we can get. But I do think that it did make us or at least for myself, so thinking, you know, where can I eliminate some of this plastic usage in the lab. And so part of my presentation, also, I use an example of one of my previous labs, how many pieces of plastic we were using per cycle, and it was 27 pieces. And what can I do in my workflow? Where can I maybe reuse some of the plastics instead of throwing every you know, when you're doing retrieval? Do I really need a new tube for every follicle that gets asked to write it? For example? Do I really need to pour it into a new dish? Every time I search for an egg, you know, where can I reduce the number of plastic that I use. And by doing simple things like that, you can really make a big difference in that now, of course, again, people don't like change. And it's difficult to implement something like that, you might think it's such a simple thing. But if you have a shortage of whatever that thing is, you use you very quickly have to out of necessity, make that change. So I'm actually curious to know if labs started using less plastic due to COVID? Because of the shortages? And would they maintain that going forward?

Griffin Jones  22:04

As far as you can tell, are we still living with the consequences of that over ordering in the beginning?

Dr. Liesl Nel-Themaat  22:10

Now we've sitting with boxes full of expired product, because people over order, because they were worried they're gonna run out. And now, you know, we in during my talk, I surveyed the audience and several people raise their hands on ask how many of you have supplies that you ordered during COVID? Because you were worried you're gonna run out and now it's sits in your storage room, and it will expired? Which shows that it was really an artificially created partially at least crisis.

Griffin Jones  22:43

Is there any application for those expired product? Like, can they be used in different kinds of applications?

Dr. Liesl Nel-Themaat  22:50

Oh, absolutely. You can use it for research purposes. You know, we all know that plastic dish is not suddenly toxic. But because of regulations, you have to follow the manufacturer's expiration dates, but any research lab would welcome it, you could even try to sell it to, you know, the research labs, but what we would do is we just donate it to Stanford's, you know, whatever lab wants to take it, I have people that some of my fellows that do research in my lab, and I would just give it to them, and they would use it for whatever research they're doing.

Griffin Jones  23:27

How do you make some of that reuse some of that limitation of usage into a system into like protocols that and processes that staff follow? I think your example of freezing a retrieval tube for aspirating follicles are maybe one of the other examples you gave. Is that up to the individual embryologist to figure out is there a way of standardizing that. So that's a process to get the whole lab is using less plastic ware.

Dr. Liesl Nel-Themaat  24:00

And that's a very good point. Actually, it's not just up to the lab, right? It is really the whole clinic. It's the physicians, it's the nurses, it's, you know, everyone, it should be like a joint vision. But for example, when you do a retrieval, there is a physician amazing is the geologist, there's a medic or a nurse, you know, there's a team of people and, you know, putting your heads together and thinking, Okay, we typically use 25, round bottom tubes. How can we reduce that number? Is it possible to you know, we take the first five, we d canted and we give it back to you and you reuse those tubes. You know, this is just one thing I can think of we full disclosure, we haven't done it. But that is one example or

Griffin Jones  24:46

we're going to play this podcast episode for everyone that you work with the whole leadership team will pass on that will go to that will go beyond the division chief to the dean of the medical school or whatever they Is it Stanford circulate this, will LinkedIn, target everybody at Stanford and play this episode.

Dr. Liesl Nel-Themaat  25:07

I think when I show the financial part of it, then I would have some big fans on my side. And when I hit the green, the environmentalists, you know, so they are people that love me people that will hates me. But the truth that we can be much more efficient, especially with plastic use, I would even go as far as saying, Have you heard of glass? You know, do you know that in the good old days, we were washing glass tubes and autoclaving them. Now by no means am I saying we shouldn't be doing that. But just at least open your mind and think about, there was a time when we didn't have any of these things. Right. And it is my one year anniversary at Stanford today. Just FYI. So if I get fired,

Griffin Jones  25:48

often there's a two year anniversary after this episode comes, this is

Dr. Liesl Nel-Themaat  25:53

a big project. And it's something that you need to get buy in from many different parties. I'm not going to say that I have made or implemented all of the changes that I'm suggesting that it's possible, but I'm trying to throw ideas out there. Because every program is set up differently, something that might have worked in my lab, that's an easy improvement in efficiency might not work in the lab next door who has a different workflow, they use different products, or they'd like a different culture system. So that's why I say that every lab person has to walk in their own lab and look at every component and ask yourself the question, is there a way I can do this more efficiency? Is there a way I can do like, Can I not use so much paper towel? Can I get away with you know, switching off some of the electric components of my lab at night and but only only the person working in that lab, the lab director, supervisor, the biologist only they can really identify it. I can't identify in someone else's lab, what efficiencies they can implement. I can just give ideas and hopefully try to get people to think about these things more.

Griffin Jones  27:03

So plastic ware was a big area paper work was another big area of those. Yeah, I think you said 23 or something suggestions of what what the most, the biggest inefficiency in the IVF lab was and you have 23 different answers. What were some of the other ones that you can remember,

Dr. Liesl Nel-Themaat  27:20

time is like a half hour. But biggest resources as you know, and that's one of the things that we have the least amount of. And I think there are a lot of things that we do in the lab that takes a lot of time that we don't necessarily need to be doing. There are procedures, for example, trimming of your egg osios side cumulus complex after retrieval, just for background for you and an egg comes out. It's surrounded by these little cells called cumulus cells. Now a lot of labs routinely use syringe needles or some other device to trim it. And then later on, take all the cells off with the enzyme anyway, to make it clean or make it easier to strip is the term we use for cleaning of the egg. But a lot of labs don't do it. And one of my questions to the audience was, how many of you people are still trimming? And I think it was about half of them. And then the question is, why is it necessary, it takes so much time it takes resources, it takes more plastic, if you can eliminate that step, you can use your embryologist for something else, and eliminate how many ever minutes from that workflow. Another thing is how many times do you wash your sperm? Right? They are practices that wash everything twice after doing a gradient. They are devices microfluidic devices, that saves you a lot of time because it's you the way the procedure works, you basically put the sperm into this device, but even culture and you don't touch it again. Now that device is pretty expensive. So you have to decide for your own workflow. What is more valuable for me here to save my embryologist time, or to not make this big expense of using this expensive device? Right? So there's always a balance, but the main Time is money. We know that. But you have to think how much does it cost me to save this amount of time? Is it you know, Palin's a doubt?

Griffin Jones  29:20

So the the device itself it doesn't automate the process? Does it circumvent the process altogether to tell me more about that. It's just a different

Dr. Liesl Nel-Themaat  29:29

technology that instead of doing manual nation steps that someone have to come back repeatedly, you just can use this device and put it in the incubator and let the sperm swim through it. But there are cheaper ways to achieve the same thing. And I don't want to go into speaking about specific products or brands or anything like that and they are things that for example, changing out your biopsy. When you do low your biopsy fragments. They are programs have changed out that tip every single time between every single biopsy fragment. And there are groups that don't. And there hasn't been any apparent difference. If you just rinse it out, you're saving on plastic you're saving on time, because a lot of times, switch out these things. And then there are ways techniques that you can use when you're doing some of the procedures. For example, XE is a time consuming procedure. But if you look at how different people are doing xe, probably everyone does it slightly different the way you set up your dish, the way you move the eggs around the way, you know how many spam you catch at a time. And by adjusting some of those things, you can actually save a lot of time I actually showed a video during my talk of I actually wouldn't play unfortunately, the technical difficulties, but there's a way that this embryologist Lisa Ray, she she she manages to hold on to an egg and then just roll it with a very swift movement, like five, six eggs in a row, just injecting jig, it takes like two minutes where, you know, if you have a differently organized, it could take you 20 minutes to inject the same amount of eggs just by adjusting how you do that procedure.

Griffin Jones  31:14

So you're in that talk where you also asking for examples of things that still don't work was that was that a segment that I'm remembering correctly? Where you ask people? If for however many years you've been in the lab, what's one thing that still doesn't work properly or, or work the way you want it to was that was that a segment that you did

Dr. Liesl Nel-Themaat  31:35

to video was on pet peeves and frustrations that people keep doing that really can be quite irritating, for example, leaving bubbles in your culture drops, you know, or using the last of a pipette and not replenishing in the in the hood, or using too much paper napkins and put it in the Biohazard. Which when it's not biohazard, and just this again, small little things that can become really irritating or people that complain that they are always the only one that does this, or does that. And if you look at the distribution, no, really, it's not that these were just complaints or pet peeves of some of my peers that were quite funny. Not writing open data, little vials and, you know,

Griffin Jones  32:28

and so some of them might be sort of comical. But other of those might point to bigger process efficiencies, you know, the writing on the vial, for example, could be something that is, is changed or automated in some other way. And as you're going through a lot of these examples, I'm thinking of the acronym, eliminate automate delegate, I don't know if anyone's put that into an acronym that is more that sounds better than EAD. But, you know, you're you're focused a lot on the elimination or because while one could say well, don't delegate anything that should be automated, you could also make an argument that says don't automate anything that should just be eliminated altogether. Are there a couple other examples that you think of either from your talk or just from your day to day work that you think, are pretty easy to just simply eliminate in the IVF? Lab? And if so?

Dr. Liesl Nel-Themaat  33:26

Absolutely. You know, you talk about delegation and automation, and elimination. There are delegation, I think, is extremely important, not only for streamlining things, but also for team morale, I really believe you have to have a strong, solid, happy team. And if you give different people specific delegated duties that they can take ownership of, I think it's healthy for the team in general that everyone knows who's responsible for what, who is the go to person for any particular thing. But then I think a lot of the things that ultimately fell on the IVF lab to handle really should not be handled by IVF. For example, sort of data entry or sorry, the initial cycle initiation, when a patient's first come through, should really be falling on the clinical team and shipping coordination. There are many of these things that really should not be handled within the IVF lab and can be eliminated from the IVF lab. Now, if you don't have a person outside of the lab, to do it, then delegate it to someone that has protected time to do that role, because it becomes quite chaotic, and it becomes a sore point if, if no one has that specific role in the lab and whoever has time has to just do it and then people that well, I'm doing it more than this person and this stuff isn't didn't have a turn yet. If you delegate everything just becomes more organized. Of course, if you can eliminate it all together, if it's not something that appropriately should be in the lab. That's even better.

Griffin Jones  35:01

I can also see though, it's sometimes easier to know what to eliminate when you do a better job of delegating, because you're isolating that particular things. And one of the things that I've started doing with my own company in the last year is it just started jotting out and mapping it alongside our accountability chart, all of the outcomes that the company is responsible for doing, you can break those into more junior outcomes, and then section those off to more junior people. And then you could take bigger outcomes that are more complex and assign those to senior people. And those often require more resource. But by mapping it in that way, it's, it's clear what can be eliminated after some time. Because if if you just have it as part of someone's job, that isn't really part of their job, and it's also kind of somebody else's job, then you don't even really see what can be eliminated. Whereas if, if you start to parse these things out, you, it's easier to eliminate? Have you found any things like in the last year or two by ft after you delegated it that you were like, No, I think we could actually get rid of that altogether.

Dr. Liesl Nel-Themaat  36:17

You know, actually, but em our integrations with SAR has done that where, you know, in the old days, something like three, four years ago, you would have to manually enter data into sources, we talking about data entry, and you know, who should do that. But most of the EMRs now will talk directly to salt and will send the data directly to salt or to NAS. And that is actually a automation step. Yes, your data entry still has to happen somewhere, but at least it is. It's in one place. And these two systems talking to each other has made a huge difference, which is also why going to electronic medical medical record system is very valuable, because a lot of clinics honestly still don't or paper,

Griffin Jones  37:06

which is amazing to think about to begin with. But put please go off. Yes. But

Dr. Liesl Nel-Themaat  37:10

I'm telling you, it's a massive investment. It's not just oh, we're going to switch to EMR. And we're going to just do it. I mean, I lived through a transition recently where we had to start a brand new EMR and it is a very, very difficult process. And there's a reason why clinics are not just jumping on it, you think but it's such a no brainer. But yes, once you get on the other side, it's great, but it's a difficult process to go through. And if a clinic already doesn't have the bandwidth, people are hanging on edge. And you know, there's budget issues. And it's not that simple. And so again, back to my point is okay, well, if you don't if you're not ready for that big step, what can you do? That's easy, that still makes a difference.

Griffin Jones  37:55

But how do you model the costs? For example, like if you so you, we started the conversation talking about different staff models, and ways of making that more efficiency more efficient? How do you model the costs so that it's easier to see for someone that has to make that calculation of should we replace this system with that? Should we should we move from paper to an EMR? How do you model costs?

Dr. Liesl Nel-Themaat  38:23

Well, it really depends on the system you're talking about, right? And let's use cry storage as an exam. Because I know it's such a hot topic right now. And I'm sure some of these automations, you're referring to refer to that component. There are various different routes you can take if you want to restructure your price storage system. But there are so many different factors to consider everything from your staffing model, you know, does your staff have the capacity to keep managing it in house? Is your practice dependent on the revenue that you are hopefully getting from your patients, those that are in fact paying? You know, at what point does it make sense for me to outsource the entire thing, but then I'm giving up a big piece of revenue, but I'm also giving up a big legal liability. And we're actually in the process of that right now. And Stanford is building this future for our careers storage systems. And we haven't come up, you know, decided exactly where we're going to go yet. But it is a, it, there's so many different components. And at the end of the day, you know, you have to have your spreadsheet and say, Okay, this is this is what I'm gaining, this is what I'm sacrificing, but how do you put a monetary value on your legal liability, you know, and what your insurance costs you every year and like Stanford is extremely risk adverse, right? Every clinic has a different tolerance for that liability. So it's not a very simple question. Something that's more that's easier to do is like the use of plastic for example, Which dish do I want to use? And I showed a table where, you know, I have two different dishes. This is what these dishes cost. The one dish might cost more per He's but then the amount of volume of oil you use for this dish is this much versus that dish. But then the media that you use cost this much, and then how long it might it takes to make the dish that's a time component. And then then in the end, you make a table and you add it all up and say, Okay, what is the most what makes the most sense, economically? And is that what we want to make our decision on workflow wise? I mean, it's, it's complicated.

Griffin Jones  40:29

How do you factor people's time into that table? As an estimate? Is there any time tracking in the lab, like how a lot of client services firms, a lot of remote companies will use apps like Harvest? Or I think another one is tea sheets? And so harvest can go in your browser? Anytime you switch windows, it can say, are you working on a different task, you record at a time it integrates with a project management software, I suspect that it's it's pretty inaccurate, or at least that it's, it is it is far from purely accurate, because it still requires so much human use to say, this is what I was working on at this time. But you can get an idea, a lot of remote company, a lot of tech based companies, this is how long this task takes. And it's just once AI takes that over, then we could really get a good idea of what people are actually working on for how long is there any kind of time tracking like that happening in the lab right now?

Dr. Liesl Nel-Themaat  41:30

Are some of the witnessing systems or try starting to track that and look into that? Obviously, it can be met with some resistance. Because there is a balance, you know, I was talking the intro to my talk was really the difference between efficiency and effectiveness right. Now, when you start going down to that granularity, I think you do run the risk. If your staff knows they are being timed, every time they do a procedure, they may start going too fast, and then start making mistakes, or, you know, maybe you see more eggs per minute, but your fertilization rate goes down. So there's a sweet spot and my my hesitation to embrace this kind of tracking of staff is exactly that is I would rather have my staff workout is a comfortable pace. And not everyone is equally fast with everything right. But it doesn't mean one that is not as fast it's less effective in your overall outcome. So yes, it is that is coming into the market, I don't know how many clinics are actually using it. I know some of the bigger networks would have their staff much more a day much more structurally. With time, at 745, you can start doing this at 752. This should be done. Now you're going to do that I can see the necessity in very, very giant big programs and how that brings in that efficiency. I don't think any embryologist particularly likes working like that. And so that could touch your team at all.

Griffin Jones  43:11

The concern that you have is one that client services firm share with their own time tracking of that, if I'm am I being monitored on this because it's down to the billable hour, and you can err on either Sen, either end of the spectrum, you can err on work completely, we bill everything down to the hour, and everything has to be tracked. And that causes a lot of stress on the team. Because one they're worried about what it is that they're spending their time on. And it can affect quality, but too often just it can be inaccurate. And they spend so much time just doing the tracking itself and the logging of the tracking that it's it's it's futile. And then you could also err on the other end of the spectrum where you do no tracking and you just don't have any. So what we done in the past, is it say listen, you're not so we never aligned it with incentives, and we never aligned it with billable hours either. And I think that helped because it was just we're doing this just to get an idea just to be able to practice, but it wasn't against the billable hours. So they didn't have to feel like it was it was for that exclusive purpose. And I also didn't want them just every single time they were switching from one little task. Well now I'm checking email minute one, but I'm checking the project management software minute two, and I'm back to email minute three. And so if you did that in the lab, and you just kind of got an idea. What do you suspect is the biggest inefficiency in the IVF lab.

Dr. Liesl Nel-Themaat  44:46

Their biggest inefficiency is not based on a procedure. In my opinion, it's scheduling. The biggest inefficiency that I think is hurting our IVF lab the most is in with consistent scheduling on the clinical side, that the lab has to absorb, that you don't know how many procedures are going to come your way at any given day, which day they're going to fall on. We know there are ways that we can do this can be done more efficiently. But this is not up to the lab. You know, that is the problem. So I know you want me to say in the lab, the most inefficient thing is how we stripping our eggs, but I don't have an answer. But I think globally, what affects us the most probably, is inefficient scheduling of procedures. And that's a big pet peeve of many, many lab directors, where there is no template with X number of slots with only these types of patients can come through on this day. And once it's full, they have to wait for the next month. I think for me, that is a big one.

Griffin Jones  45:54

I could just say I will save that topic of how to fix it for somebody who speaks on scheduling. And that's their topic, but let's try to give them a little bit more to work with how, how do you suspect that can be improved? Yes. So

Dr. Liesl Nel-Themaat  46:08

what I have seen was very successful was when scheduling is outsourced, where it's centrally controlled by someone that is not emotionally pulled into the decision or have to make a decision on the spot. Because what we often hear is, Well, this patient is so nice, and she wants to go to Italy for her vacation, can we please add her. And now I'm standing there with the person making the request. And I have to make the decision right now. And the problem is for other very nice patients to scold three of the other doctors. And before I know it, I have five more patients than I can safely managing the lab. So by taking that off of the labs plate where this is centrally controlled, only the lab can make kind of proof an addition but I'm not dealing directly with the physician or the nurse or whoever has emotional relationship with the patient. You know, I think that has made what I've seen when, you know, during transition that I lived through that made a huge difference. When you

Griffin Jones  47:19

say centrally controlled, you mean like that scheduling function outsourced altogether, or simply concentrated somewhere within the clinic that it's not just the doctor doing here, the

Dr. Liesl Nel-Themaat  47:30

example I'm using is, you know, in a network and a big IVF practice network that was centralized by scheduling department that was not even on site where we were. But in a standalone clinic, you can have a person responsible for that. That's not part of the clinical team that doesn't have a relationship. And that person should have the authority to say yes or no and follow the rules. There's a reason we have a template, we know what would be an exception. For example, if I have a cancer patient coming through that starting chemotherapy next week, and we need to freeze her eggs 100% That is a legitimate reason for an exception, someone that wants to go to Italy and she doesn't want to wait till next month, that's not a reason, insurance expires, you know, but that needs to be written down in a policy. And if an answer to make a change, or to deviate from the rules is no then that should be no and everyone is on the same page. And it shouldn't come become emotional decision between the lab director or lab supervisor and the doctor

Griffin Jones  48:41

is that where the bulk of the problems are coming from with regard to scheduling and your view just from trying to fudge in different exceptions at different times?

Dr. Liesl Nel-Themaat  48:54

A lot of it is yes, also communication, you know, you hear of patients that suddenly appear on the schedule and that patient was never presented earlier or was not planned in advance. And somehow there was a communication gap that the lab somehow didn't know that this person was coming until the day before. Also just you know, the clinical practice. Now, I'm not a physician, I do not, you know, have no input in the stimulation protocols or the treatment plans at the patient's other than what happens in the lab. But we know there are ways to manage the volume of patients how many FTEs and which days they fall on by just doing program cycles, right? So and same with retrieval cycles, you know, do we do birth control or not we you know, some patient wants to be on natural cycles. But that is something that really the clinic should be everyone should be on the same page and the physicians, not everyone likes to change the way they've traditionally practiced medicine and there is still in the list. The chair, not there's not really an agreement on if if it affects outcomes or not. But I know that most of the large networks do have better workflow because they have these scheduling rules and templates. And the majority of the cycles can be predicted because they use program cycles instead of natural cycles. But a lot of divisions are are not comfortable with that yet.

Griffin Jones  50:32

Is this an argument for batching? Or is that something different?

Dr. Liesl Nel-Themaat  50:36

batching is something a little bit different. But for batching, you definitely need that's not natural cycle, right, because you have true batching, you do one week of basically, sometimes it's just two or three retrievals data retrieval days a month. And then the lab is very, very busy. But you know, what's coming your way you can plan accordingly. And then people can, you know, during the downtime, catch up on a lot of the administrative stuff, and, you know, ordering and setting up the lab and get ready for the next cycle. So true. batching is a little bit different. This is just basically managing if you're not a batching clinic, just managing the flow of your patients coming through.

Griffin Jones  51:22

Well, I want to let you conclude with what you how you would summarize remedying and efficiencies in the IVF lab where you would like to see things go we have a lot of lab directors and embryologist that listen to especially when we bring on someone to talk on a laptop, but we also have some CFOs listening that are responsible for p&l, and we have practice owners. And so some of that support on the clinic side. And we do have some DIVISION CHIEF So there are people thinking about how they can get through the red tape, but their health system? How would you like to conclude?

Dr. Liesl Nel-Themaat  51:57

Definitely saying that, you know, we talk now quite a bit about, you know, stimulation protocols. And you know, whether it's programmed on program cycles and how that affects scheduling, every clinic is different, right? What works, one clinic is not necessarily going to work for another clinic, which is why it's important that you have to within your own practice, put on the hat of what can I do to be more efficient in all these different aspects of my practice? What will work for me may not work for you, right? If if I say I can eliminate this process or delegate this process out of my lab, the way in a neighboring clinic is set up, it might not work at all. So the most important thing is to just be searching for ways that you can make your practice more efficient. The one is not right and the one is wrong. It is very individualized because everyone is doing things differently. Just wear the glasses off. I want to be more efficient. What small changes can I make sometimes mighty big changes, but what can I do right now to become more efficient? That could be my message.

Griffin Jones  53:09

Dr. Liesl Nel-Themaat, thank you so much for coming on inside reproductive health and sharing this for your lab colleagues and your colleagues and the rest of the field

Dr. Liesl Nel-Themaat  53:19

is a pleasure.

Sponsor  53:20

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

183 One Set Of Protocols For 250 Fertility Doctors; Featuring Dr. Kshitiz Murdia, CEO of Indira IVF



Some practices can’t get two fertility doctors to agree on a set of protocols.  How about >250 physicians?

Dr. Kshitiz Murdia, CEO of Indira IVF discusses the enormous growth of the Indira network in India, how their approach to IVF practice management differs from the US’, and how they tackled massive obstacles (such as patient education)  along the way.

Listen to hear:

  • Indira’s massive marketing and awareness programs.

  • How to transition out of your clinical role, to a director role, and finally, CEO.

  • The due diligence regarding private equity groups that took place before the majority stake sale of the company.

  • How Dr. Murdia got out of the ‘conributor seat’ and into the seats of integrator and visionary.

  • About the standard operating procedures Dr. Murdia and his team built, and the training and management system that backs them up.

  • Griffin press if standardization in protocols is antithetical to individualized care.

Indira IVF Hospital Pvt Ltd Website: www.Indiraivf.com

Transcript

Kshitiz Murdia  00:00

it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time during the same cycle and the protocols should not differ the language that they speak should not differ.


Griffin Jones  00:24

250 fertility doctors 50 IVF labs 60 to 70 satellite offices 27 to 20,000 employees did I get that right? These are my notes from my conversation with the CEO of Indira IVF, one of the largest fertility clinic networks in India. His name is Dr. Kshitiz Murdia.  He joined Indira IVF as the second physician in 2010 2011. By 2014, they had 50 locations. We talked about that process first starting with a massive marketing machine doing awareness camps across the country to generate awareness for infertility and fertility solutions. And then for their practice, we'll talk about how after three to four years, Dr. Murdia has stepped out of his clinical role and then transition to CEO first as medical director and then when they sold part of their company, or maybe a majority stake of their company, to ta associates becoming CEO, and the due diligence process with private equity groups before that, that gave him that financial and HR and marketing ops background education. I think this is a really good example. For those of you Doc's that I've talked about when I've pointed the accountability chart before and lots of articles that I've written, I talked about the entrepreneur operating system, and how many of you practice owners are in multiple seats. In the visionary seat, you're in the integrator seat, you're in different seats as contributors in physicians, you're in different management seats as medical directors seems to me that Dr. Murdia has done this, as well as anyone has of getting out of those contributor seats and moving into if not the visionary and integrator seat, the visionary seat, I think really behooves you to pay attention to how he did that in terms of building standard operating procedures, his process for building standard operating procedures in different areas and the training management system that backs up those SOPs, we spend a lot of time talking about creating one way of doing things proven way of doing things, having a training system, hiring management, and not just building the airplane as you're flying it and do IVF is apparently done this so much so that with 250, fertility doctors in counting, they have one set of protocols. There's one protocol for each patient type. I tried to play devil's advocate for you because I could see that driving some of you crazy, but I think the variance in protocols is an issue of scalability in fertility clinic operations, I can't vet whether that's necessary or how necessary it is, but Dr. Murdia responds to it. This is a very large operation that in 2019 ended up selling to ta associates the private equity firm that had owned CCRM and they have a massive HR and operational infrastructure behind them. Dr. Maria details that in this episode, so I hope you enjoy it. Dr. Murdia, Kshitiz Welcome to Inside reproductive health.


Kshitiz Murdia  03:19

Thank you Griffin. Thank you for having me on this show.


Griffin Jones  03:22

I promised my audience that I was going to cover more of the IVF market in India this year, we have you know, the third guests that we've had in 2023 to talk about the Indian IVF market because it seems to be expanding like no other market right now. At least I see. It seems everyone that's quote unquote, industry side, if you look in their LinkedIn profile, there's a picture of them visiting India, there's a picture that I'm talking about their company expanding in India, whether it's a genetics company, or a software company, or one of the pharmaceutical companies and, and so there seems to be a lot of activity, and we'd like to talk about that activity. I'd like to talk more about the present in the future. But in order to talk about the present in the future, I'd like to just talk a little bit about your enterprise in dira IVF. And, and how that got started. And can you give us a little brief history and where you are today?


Kshitiz Murdia  04:18

Yeah. So Griffin in Dr. We have started the routes are started in 1970s 1980. When our chairman Dr. Jim odia, he published his first paper on male infertility, which was published in The Lancet incidentally, in the same issue when the first test tube baby was reported by step two and Edwards back in August 1978. Since then, he has been very active, but particularly on the male side of infertility, because that time it was a big social stigma and a taboo, that males also could be responsible for fertility and everybody would put forward the female for checkups for investigation and the other things. So to bring that concept back in nine Getting a deal and especially in a country like India, it was a big, big problem statement, I would say, to talk about male infertility to ask the male partners to come forward for investigation. So he took this great step, I would say back then, and he's been practicing from 1980s. And then he started his own clinic in 1988, primarily focused on male infertility made diagnostics. You established his one of the first sperm banks in the country in India, where Neil's suffering from a zero sperm count could benefit. I am a gynecologist. I joined him in 2010 2011. That's when we revamped the whole setup, started doing IVF for the first time, in one small town in western part of the country, which is the poor, it's a very beautiful city, I would say I mean, a lot of tourists. So we revamped the setup, we started doing fertility surgeries, we started doing IVF for the first time, back in 2010, my brother, he joined me as an embryologist. And then we used to be home combined jointly, all three of us used to practice from 2010 to 2014, we were pretty much limited one center that we started back in the bowl with the western part of the country. And then we soon realized that there is a lot of awareness gap in the country that people are not aware about the scientific practices. So we should go out to people, we should organize these pre patient awareness camps, run a campaign in the country, educate more and more people about what fertility issues are, what is the medical scientific treatment, how much it could cost, how much days of treatment it might take. And we started taking these awareness camps. And then I think I think in the last one decade, we must have taken more than 2500 camps educated more than 70,000 couples about infertility. And that's what set up the route for our brand, I would say because we now proudly say that we are the we are the only b2c brand of IVF in the country, which is directly to consumers. And it's all started because of these awareness camps that we established long back, I think the second biggest challenge in front of us was around affordability. Because all said and done IVF might be cheaper, in some sense in the country in India compared to the Western world. But if you compare the disposable income of of the people here, for for an average middle class income, it could be, you know, a year or two years of their salary that they would have to spend, and it's all out of pocket, nothing is covered by insurance. So I think the second major challenge for us, apart from increasing awareness was around affordability, how can we make the whole treatment very much affordable. And then the third challenge in the country was around accessibility, because majority of these IVF centers were situated in the metro cities or the bigger towns, and then, you know, people would have to travel all the way stay there. It's a longest treatment, two or three visits, spanning over three months. So again, it was a big, big challenge. So we started opening out clinics in other parts of the country. So the idea from our side was you go to the patients and explain them open a good quality clinic with a better outcomes near to their locality. And that's how we started expanding. So 2014 was our first center outside the base location with paper, which was in Pune, which is in Maharashtra. After that from 2014 to 2018. We were at 50 centers 2018 to 22. We were at 100 centers. And we quickly adopted the hub and spoke model where we said we can't go to the smaller towns and villages with the whole stack of the bigger fertility hospital, let us do something which is a smaller capex a smaller model, which we can also go into the smaller towns and villages are lesser investment I would say. But at the same time ensuring that 70 to 80% of the IVF treatment is being carried out at that one sector and that smaller spool and then only for the critical operative procedures for a day or two days or three days maximum. The patient would have to travel all the way to the hub are the main center. So I think accessibility was a key thing that we quickly addressed back in 2015 16. And then we started having these folks also in the smaller cities


Griffin Jones  09:41

was it retrievals and transfers that were done at the hub and everything else was done at the spoke all the testing the monitoring the console that was all done at the the satellite offices,


Kshitiz Murdia  09:55

so we would have a full time gynecologist working at the spokes also and all week. interpretations, the stimulations, the ultrasounds, the monitorings, everything would happen in this book, only the retrieval and transfer was done at the end that reduced the number of visits at the hub for a patient.


Griffin Jones  10:13

And so you've got three days it sounds like awareness, affordability, accessibility, it sounds like awareness came first that you laid the groundwork of doing some marketing of getting people familiar with what the challenges they were facing, and then what you did and sounds like you did that before you built some of your your spokes. Now, what is involved in those patient awareness camps? Is that something that is it is that an event that they attend,


Kshitiz Murdia  10:44

we organized kind of an event where all the patients are called, we do marketing in the newspaper, digital and other ways of marketing that this kind of doctor is coming for a consultation. And any patient who requires this type of fertility consultation can come there. And at Indy cap, it's a free awareness camp, we take a one hour video session through a PowerPoint presentation explaining the normal fertility process, where could be the problems in the male part and the female pot, and how IUI and IVF and exist can overcome these certain problems. Which patient category should go for conservative for medical management for IUI than for IVF. So at least they are aware, and they are on the scientific path of the journey for treating their their fertility problems. Do you still do the awareness camps? Yes, we still continue to do that. How have they changed


Griffin Jones  11:38

over time. So if you started doing them in 2010, or whatever, this is kind of pretty socialist as as people are getting on social media. Now today, they have all kinds of information in social media. So in 2010, I suspect that that information may have been now to them. Contrast that with 2023 where they've got recordings that you have done, they've got recordings that your Doc's have done and and probably they can watch old camps that awareness camps they can watch on. So how is the awareness camps evolved as social media and digital info is increased?


Kshitiz Murdia  12:15

Pretty good question, Griffin. I think because we've also seen a lot of change in the last 10 years earlier, I think when we used to organize this camp used to have 200 plus couples in all the bigger cities attending the camp because information was not freely available. So those were mega camps, we used to register a lot of people and they used to come forward for treatment. And our our our contribution also from the camps and the print media, which is a newspaper was much much higher, before COVID, I would say, which was around 50% or 50%. Plus, after COVID. What happened in the country, it accelerated the digital adoption of everything, whether it is its digital payments, or consuming the news articles, or seeing all the Facebook's Instagrams and Google and all those things. At present, I think our digital media contributes to almost 56 to 60% of our footfalls that are happening to the center. And now we have slightly changed the format of the camp where we don't go to the places and invite people to marketing. It's very focused with some local doctor there in the community who was famous with the Kinect, and then they would have some patients. So we our doctor would travel to their their center in advance will let them know that we are coming on this date so they can gather all the fertility patients so it's more of a I would say a doctor clinic that way where we would use those camps to be organized. But yes, yeah, I think it's it's dramatically changed from what we used to do. But earlier I think two or three people from from our family were doing these camps and now we have 20 plus doctors and India at one time. So that has added too much of power to the entire organization.


Griffin Jones  13:59

And I want to talk about what went into that growth the operational logistics behind the growth I do have a side question about involving the local doctors because one debate in the US is how much obg lands that are not Rei what certified they're not Rei fellowship trained how much OBGYN is can and should be upskilled or trained to do things up to an including IVF retrievals. And, and so there's there's debate on how much they should be used. But there's definitely a camp of folks that do want to involve OBGYN more and some of them have had challenges I believe with recruiting OBGYN to be part of their network because when you have someone who's businesses also who is also to do obstetrics, do gynecology, then they feel like their patients are being taken away if if if you're using another OB GYN so how did you navigate that when you were when you're leveraging these local doctors So how did you avoid the rivalry that they might have with other doctors in that area?


Kshitiz Murdia  15:08

So first of all, Griffin, I think there's no concept called reproductive endocrinologist in the country. It's OB GYN only, which would be doing obstetrics and also IVF after a certain amount of training that is required by law. Secondly, our volumes of these kinds of b2b interventions, so called I would say b2b Now, because b2c is direct to consumer b2b. So these beta channels is still in the range of 10 to 15%. The good part is we don't do obstetrics. And we don't do deliveries of our own patients also. So you know, when the patient comes to me for IVF, they would go back for the obstetric work or or the routine antenatal follow up to that particular note. So we don't have a rivalry in in that sense it's a symbiotic relationship.


Griffin Jones  15:55

Well now with neither but if you're if you're using these doctors for your awareness camps in your involving the local OBGYN then how would you not tick off the other OBGYN in that area that say well wire? Oh, well, if Indira is using Dr. So and so then I'm not using Indira


Kshitiz Murdia  16:11

No. So we have a list of top 20 or 30 gynecologist in the in the city who are actively involved into fertility work and we keep rotating between all the doctors we have tie up with all the doctors, we do send delivery patients the obstetric work of our own conceived IVF cycles to all these doctors. So there's a symbiotic relationship. And then we are always there as a as a service provider to help them in their procurement to help them their pathology labs or any audits, any trainings, any any software upgrades, anything that we as a platform can add value to their practice, we are more than willing. And I think that brings me to another important point Griffin is is around the doctor recruitment as to how we have done it because ours is a b2c brand and patients are coming to Indore IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such an such doctor or get treated by such and such a doctor. They just see in the eye we they would come to in HR IVF. And then they would get to know who's the doctor treating them. And every other day we have a roaster. So somebody is consulting today, their pickup might be done by a separate doctor, they impertinence or might be done by a separate doctor. It's as per the these Can you hold the roaster in the clinic. So it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time. During the same cycle and the protocols should not differ, the language that they speak should not differ. And that's why we started this in the RAF fertility Academy back in 2016, which is one of the world class adopts in training in fertility. Our training center has been recognized my recently while British fertility society. Our training center is recognized by Merck foundation in Egypt. They regularly send Africa and Indonesia and Malaysia and Vietnam War the Asia Pacific doctors for training we run a fellowship program with them for three months. And 99% of the doctors who are working with us have been trained to our own fertility Academy. And same with the embryologist also. And once we got a hang of it, we understood that you know, IVF is not so difficult. It's not rocket science. You know, every gynecologist and life science postgraduate could be trained into either being a IVF doctor or an embryologist either ways, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP don't bother about the final outcomes, final outcomes are bound to come. And we've been very successful. I think the average age of our doctors is 35 or 36, in spite of, you know, a few doctors being with us for almost 10 years now. So that gave us a very good handle on expansion because the expansion the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure, you everybody has deep pockets everybody has private equity money, you can fund 100 centers in one year, you have the infrastructure available, you can buy a spaces you can rent them you can do I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of skilled manpower in whichever field you go. And we decided that we would not struggle with this part. Let us create our own skilled manpower let us not depend on the market to get skilled manpower or to by practicing from doctor that you know, some such dope some work done or having good practices in it. Nigeria, you just go and acquire them? We said, No, let's have a b2c brand being built up, let's fuel the pipeline for recruiting young talent for for training them adequately ensuring that outcomes are as good as senior doctors. And now we regularly plot the outcomes of every doctor who's working with us, whether it is their one year experience, or six months experience versus their 10 years experience. And we see most of our doctors fall within a very narrow range of success or outcomes or embryo transfer outcomes. And that's all because of the structured training process, I would say and the strict SOP that every doctor has to follow with the team. So I think the overall strategy went to well, when we started expanding is one on a b2c brand, recruiting a very young talent pool, adequate training men, ensuring that they follow the SOPs, and then the outcomes are good, and then the word of outspread. And then again, b2c. So the entire circle went well, with the overall strategy that we wanted to explore.


Griffin Jones  21:02

And finally, it's interesting, because I've been thinking about this from my own business recently, that a shortage of skilled manpower, however you want to phrase skilled talent, or, and skill can be a relative term means meaning the talent that you need in order to fulfill your delivery obligations. But I have been thinking about this a lot for my own company recently, and how that's more important than getting the funding at that particular time, or at least in some instances it is. Now tell me a bit about that. Because many people would say, Well, no, we dive in more do we need the venture capital money in order to be able to build the SOPs, in order to be able to hire the manpower, we need this private equity, we need this debt. So tell me about how it can be more important to to fulfill that need of a shortage of talent and have the training processes the SOPs for them, then then the funding itself.


Kshitiz Murdia  22:05

By the way, I think carefully, it is a it is a multi stage process, you can't achieve everything on day one. And then you need to decide as per your business, the the line or the field or the vertical that you're in, what is the most critical thing. So, you know, whatever we are today, we were not even 10%, I would say five years back, or 10 years back. So 10 years back, the most critical part, the most shocking part of the bottleneck for us was training, right? So we focus first on training, we never had Oracle or the best ERP systems or the best tech platforms that we would have today. But I think I think that was the need of the hour. So as as a business as a company, you need to decide there could be 10 things that you want to achieve in life, but then it has to be staged in a five to 10 year horizon, that these are the two critical things or one critical thing that I need to achieve immediately in the first year. And that's what we did. I think the first part was force force training. And obviously, we focused very hard very heavily on training demand. But I stepped back within, I would say, three or four years of my medical practice that having done more than 10,000 cases, I had to step back from the active clinical practice. And I used to only and only do training of the new recruits and focus my 90% of the time, ensuring that they follow the right protocols have been trained, they follow the right clinical procedure, their skills are to that level. And fortunately for us, IVF is not a very skilled procedure, I would say normal delivery is much more technically skilled or riskier than doing an IVF cycle. So I think I stepped back from active clinical work from all that thing. And then ensured that, you know, I would provide training to all my new recruits for joining in my brother step back from the active embryology working but involved in training. So I think I think both of us dedicated too much time into the training part, having those SOPs, our SOPs might not be in the form that are there today, like you have a booklet and SOP written by this person, reviewed by this person at this didn't change and that date, but they were very primitive shape. But that's fine. I mean, you know, you need to have some SOP in place that this is how you would work. Maybe it's not in the best of the forms of formats that you would require. But I think that's that's what we did. And then then started the journey of having quality auditors, you know, somebody external parties could come in validate whatever you're doing whatever work. I think the third important thing that we took up is building a solid management team, which got completed three or four years back at we have senior people of experts working in their domain like finance it HR or medical or tech, having worked for a decade or two in various other multinational companies and get all of these people together and showed that there is a chemistry between the entire senior management team, they understand healthcare, they understand IBM, set up the goals with them as to what we need to achieve in the next two or three years. And then once everything is fine, then you look after, I mean, for us, Tech was important, but we consciously delayed it for some time till we had the proper team in place, because you need good quality people to to develop those IT platforms that you would want. And once we've developed the ID platforms in the last two or three years, two years, mostly, then is the is the hard work of ensuring that everybody does a shift in the practice from the pen and paper system to a fully integrated digital end to end system. So I think I think we, we very consciously understood that these are the challenges, but what is critical for the business has to go first, what is good to have could take, you know, little later timelines and that's how we went up. And I'm starting


Griffin Jones  26:00

to feel validated today as you're validating some of what I'm working on for my own business. Right now I've owned fertility bridge as a client services from doing clinic marketing for many years now. But in the last year or so I've been building inside reproductive health, not even really focusing on building inside reproductive health as a trade media company. So the inside of reproductive health is the Wall Street Journal is the Financial Times that everyone director level and above in the fertility industry worldwide, reads every morning listens to every morning. And so in building that my natural tendency is sell, sell and then deliver. And I've realized at some point that way, okay, I don't need to do crazy selling right now I've got enough money, I can figure out a way to do some of this other stuff. And every time I sell, I'm increasing my delivery obligation, meaning what I Griffin have to do in order to fulfill that order that I just sold. And then my bet is that if I sell to an advertiser that could mean 20 hours of my time for that one advertiser. And am I better off selling right now just to get more money in or whatever? And, and then having to use 20 of my hours to fulfill the order for that client? Or am I better off with those 20 hours working on the operational systems, the training systems, so that we have the people in place to be able to fulfill and the answers, obviously, the ladders, like, Okay, now, I'm really just selling a couple people here and there to continue to validate the concept to make sure that the systems we are building are actually applied to real people that they're not just hypothetical, but there's way more emphasis on operations and delivery. And you're the first person I think that I've heard talked about that on the show, I think most of the time, people are very much building delivery while they're building the operations, because they have, you know, they've sold the private equity, or they have so many financial obligations, and they need to meet them right now. Why do you suppose it is that high growth, companies overlook that, that period of really building the SOPs and the training and the hiring of the people and not trying to build the airplane while they fly it?


Kshitiz Murdia  28:25

I think that's one of the very critical things is building a good foundation. And I mean, good foundation, you might not be able to build right from day one, after you progressed a little while and you got success in some area. And that's where you, you start building the solid foundation for a sustainable growth. And I think for us, that insight came from our private equity investment team associates, Boston based private equity firm invested with us in April 2019. And their their philosophy or, or their way of looking at business is always to have a strong management team have a good corporate governance, you know, in order to have a sustainable growth, I would say. So I think a lot of interventions that we did on building or correcting the foundation, which is which is currently now a very rock solid foundation that you know, business is not dependent on one critical function or one critical person. It's an ecosystem that is running on its own that has a great solid foundation. And even if one vertical or one function or one person is not performing well or certainly go out of business, you know, you certainly don't flatter and then your business continuity there. And obviously ensuring that you you are true to your patients you are not, you know, over promising or doing false promises or doing something short term that would help you. It's all about that mindset of having a long term view, having a sustainable view, having good corporate governance, because it's all about wealth creation. and not earning money every day, which is which is much more important for for private equity or even for the shareholders. Once you get to that mindset, you will start thinking your all your actions would start getting pointed towards wealth creation or value creation rather than earning certain dollars every day or every month are looking at the p&l everyday.


Griffin Jones  30:20

So there's two routes that I want to go with this conversation one has to do with your background and the other has to do with the SOP and and building that structure for SOP. So let's do the second one. First, let's talk about how you built the structure for SOPs. Because as I'm building more standard operating procedures, I'm also realizing Okay, I need an umbrella governance for how SOPs are created. Because if you have sales team creating sales SOPs, and you have operations, folks creating operations, SOPs, and HR people creating EHR SOPs, they could start to look different from each other. And then they have to be Jigsaw together later. And so it's better to have a certain governance where you have a master process for how processes were made. How did you approach that?


Kshitiz Murdia  31:09

So I think my personal view, Griffin is start from the very basic things that you could achieve very quickly, rather than waiting for the entire structure to fall through from the top because you know, that will involve a lot of skilled manpower, we might or many companies are not at that stage, when they start on middle of their journey. I would say even if you're able to achieve 60%, up 70% of what you want to achieve tomorrow, let's do that, rather than waiting for one year to achieve 80 90% 100%. And that's the philosophy that we followed in all the tech developments. Also, you would want a certain page to look like in a particular way you need 10 fields, here are five fields there are the critical are they showstoppers yes or no? If it is, yes, otherwise, even with that 50% of the period, if I'm good to go, whatever I'm doing today, I'm able to do 80% of that on a digital platform or an SOP or any other thing, we would just go ahead do it. Because there are multiple challenges once you put it to the user, there are bound to have all these questions and debates that would come up that they need certain changes that they need this, they need that, you know, and it will be a continuous process of development. So don't wait for the final end stage of how a corporate governance structure should look like and ditching trying to stitch it on the very first day, it is very difficult to achieve to that level. So I mean, all of us are very fragile in the leadership team at Indore IVF that we very quickly adopt the process let us start knowing fully well that we need to reach to this stage 100% But not to be or tomorrow, maybe after three months or six months or depending one year. But this is what we want to start today. And let's go ahead and build it up.


Griffin Jones  32:56

Did you have the embryology team making their own processes? Did you have the nursing team making nursing processes and physicians making the metal starting with the Medical Director presumably making protocols? How did how did individual process areas come to be?


Kshitiz Murdia  33:16

So we had different different verticals, making their different policies and processes and then, you know, problems are bound to happen whenever problems come all of us would assimilate as a group and see what changes we need to make in the various processes, but certain of the medical and the medical excellence so we have one medical department who's responsible for all the clinical and embryology processes, we have a separate medical excellence department who looks after all the medical protocols, whether they are safe for the patient, whether they are done rightly, in our patient identification, facility management, all the we screen our centers across 498 points spread across 12 different chapters of a credentialing program, and then everybody has to match that program and and the medical excellence runs very independently of the medical core function. So they would very closely interact as in when if there are problems, so I left it we have 70% Correct. But you know, all these issues would keep coming up every now and then in you sit together as a group and align the overall strategy. What is the culture? What is the DNA of the organization? How should in the IVF react in a particular situation? Is is what would govern the changes in the SOPs if required?


Griffin Jones  34:32

Did you put this all into one master document or didn't live All in One Drive? Where does that does each SOP area live with its own department?


Kshitiz Murdia  34:46

So it's mostly in the HR we have a learning management system. So all the policies procedures, everything has been feeding into the learning management system, and different people based their job roles and their category or We create, they keep receiving periodic emails of certain courses that they need to complete. And also we have a very active learning environment. So every week or every 10 days, there's a separate team learning team separate over take care of all the new join is the new recruits, take them to the entire mission vision values, to the basic trainings, the clinical aspects and other things. When did vision


Griffin Jones  35:23

mission and values come in as a central part of the training did that come after you had been building some SOPs? And and then you needed to start gluing all of the different areas together? Or did it come from the beginning?


Kshitiz Murdia  35:41

No, you it came in? I think I would say three, three and a half years back and not 10 years back? Yeah. feverishly add some SOP some I will also not say a full fledged SOP document, it's a way of working could be some verbal trainings or other things or some PPTs that we would have. It all eventually came in the last five years, I would say one by one.


Griffin Jones  36:06

And so your training management system? Is that proprietary Training Management System that it for India? IVF? Or do you use something like train you will or loom or any of those softwares?


Kshitiz Murdia  36:19

Yeah, we have a software from adrenaline, which is an HR software, which is our HRMS, which has the learning modules when we have all the videos being uploaded on the learning module, and then it periodically keep sending reminders to all these.


Griffin Jones  36:34

How involved were you in selecting that solution? Did you have your HR folks do it? Or were you personally involved in choosing that solution?


Kshitiz Murdia  36:43

Yeah, I got involved in most of these softwares selection. And obviously, then the implementation and the customization, we involve more the business side rather than the IT side. So all our our, our eh is the EMR the medical function has developed, it has supported our ERP implementation the finance team has done it has supported similar to the HR system. So we had this very different approach that let the business drive the implementation of software's rather than it doing it and then they send it to business and business will have 10 things to circle back to the it. So we thought let's involve the business on the very first day, and it will be like a support function of converting the thoughts into the ID language. That's it.


Griffin Jones  37:31

So that makes sense of why business would be involved in choosing the talent management or the resuming the Training Management System. But why you personally what is it that you were looking for?


Kshitiz Murdia  37:44

So because we, me and my brother, we had seen various systems in the last 10 years, we tried implementing EMRs, we failed on three attempts, I think. And that was to do because one, it was not thoroughly evaluated. Second, when we were growing very rapidly, from five centers to 25, to 50, to 100, your requirements kept changing every six months. So by the time you evaluate the software, you feel happy, they come back, they start implementation customizations, your requirements have gone, then x of what they were six months back. And that's why we were not able to you know, properly implement it. Secondly, we never had a good management team or leadership team. Because you require enough bandwidth to implement all the IT processes. It's not just implementation or customizations, you require good change management that should happen at every level, every person was using the software. So I think I think that because of all those things, we could not implement great it or tech platforms five, six years back when we tried and we failed twice or thrice. But once we have a good leadership team good management below us, we are also grown to 80 or 90 100 centers, pretty much our requirements was fixed, I would still not say we were 100% clear on what we were now also as you go, and then you know, business would require 10 More things. So anyways, if you're 80% there, just go in and implement it. These things would keep coming in people would want the moon and the stars. And then you can keep building on it in the next phase. Yeah, they'll


Griffin Jones  39:19

always want something more. So they always will be in a next phase. How did you go on this journey to CEO? What were the milestones as you look back now because your training is as a physician, right? So you started off seeing patients and you're trained as an OB GYN. And then how did you become a CEO? What do you look back and see as the most significant milestones.


Kshitiz Murdia  39:45

So I think initial three or four years I was practicing as a as a gynecologist as a physician doing active clinical work while all the ultrasound pick up after surgery is everything. After three or four years when we started expanding In, I took a little back seat from the active work started working as the as the trainer, I would say for all the physicians and other things. But once we had five or six or seven centers, I started acting as the medical director, being responsible for all the protocols being responsible for all the trainings, being responsible for what medications they would use, what would be the doors, what would be the prescriptions like and all those things, after being the medical director for maybe two or three years, and then ta invested with us and T was wanting to put a proper governance and a corporate structure that any private equity would want. The idea was to select somebody working with the company for for last few years. Because you know, when T invested, we were already at 50 Center, we were the largest in the country, in terms of number of centers, in terms of doctors being trained in terms of business. And in the overall top line. I think the idea from the side was nobody has done good work in the country in India in the IVF suite apart from Indore IVF, let us have somebody from the group internally and promote them to the to be the CEO. And I think because of some of the diligence is being done on the company before they invested. So there were a couple of private equities, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. So I think I think it was because everybody, all the shareholders thought that I had a very broad based idea about the business and not just the medical function. And obviously, we are very strong believers that our medical organization should always be headed by a doctor, because that gives you much more leverage in terms of talking to the doctors, because ultimately, all these businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on Excel or laptops or you can't build a business, their business is actually being done at the clinic level by the clinicians, by the nurses by the embryologist. So you will need somebody who could have that wavelength of talking to these doctors who the doctors will also respond to and respect. And it's not just about number number number that you need to clock certain revenue, you need to block certain number of patients being treated. It's always more to do with the medical outcomes, and how do you treat and how do you excel in, in the overall outcomes, I strongly still feel that a non medical person, no one sounds very commercial to the doctors, doctors would not give that much of respect. Because, again, they feel the other person has no knowledge about medicine, and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And you know, patients are different, the actual clinical life is different. So I think a good balance between the medical and the financial work is required when you want to control the doctors and when I say control because ours is a very different culture in DNA. It's not doctors independently practice in in their own world. And they have a different protocol. And they have a different business mindset. All of us all the 250 Plus doctors are run on a single platform, run on a single protocol, everybody is in very close touch, I would say everybody's using the similar protocol.


Griffin Jones  43:30

So you need a doc at the top in order to get that many Doc's to buy into similar protocols. I think I think that's hard enough for you even if you have a doctor at the top. And so that makes sense to have a physician as the CEO, but you said that it was doing some of the due diligence, with the private equity companies that you were talking to prior to ta associates that gave you more education and finance and HR, how much education, finance and HR did you have prior to those due diligence process?


Kshitiz Murdia  44:04

I think nothing I had no background about an ENT and other things. I think those diligence process exposed me to many more technical terms in the finance, what is revenue, what is collection and you know, EBIT da and all those things I started learning, of course, now having being the CEO and interacting with all these lovely professionals that report to me and are experts in their field. I have much more now control and handle and knowledge on the various marketing functions, the HR, the tech, the operations, the finance, the medical excellence, everything is, is pretty much there because they've they've they've taken the company to an extremely high level in terms of governance and compliance beat any field, whether it is HR or medical excellence or idea of finance. So I think I think that initial exposure helped me a lot.


Griffin Jones  44:54

How did you adapt to what it must have been drinking from a firehose with That level of information trying to keep up with those folks, what resources or education? Or how did you lose it just articles on the internet? How did you get up to speed?


Kshitiz Murdia  45:11

I think I was very open to all of them during the journey. If I don't understand anything, even being the CEO, I will be very open and upfront, and I don't understand this, pardon me, I'm a doctor. So I might not understand just explain me. And obviously the the you are running the business from day one. So you have that business sense. And you could catch up things which is in the interest of the business or not in the interests of the business. So they would say that I then simplify those films for me and explain me a you know, if I'm not able to understand, you must have


Griffin Jones  45:45

caught up and in you did so in a way that has really allowed you to scale and pretty darn quickly, it seems from especially starting around 2014. And then seems to have escalated quite a bit. You talked about having a one protocol, one set of protocols for all of the doctors and you said 52 Doctors was


Kshitiz Murdia  46:06

that goal goal? 52 plus 250 plus two. Okay,


Griffin Jones  46:09

so over 250 Doctors Wow. And everyone's using the same set of protocols. In the United States, it seems that people are resistant to do that. And I'm not clinically trained. And I come from a sales and marketing background. And I just kind of observe and it seems to me, like people are very reluctant to have any kind of uniform protocol. That's all we always let the doctor practice how they want to. And I think as a business person, I think what's pretty darn inefficient, it seems fine, but I'm not clinically trained. You you decided that that was the right way to go. What do you what do you what made you decide that? And what do you think the resistance to that idea is


Kshitiz Murdia  46:50

very interesting, when I think when I started practicing I was 29 or 30 years, when I recruited the first doctor, I was 33 or 34. And then purposefully, I would want to recruit a younger doctor who was little junior to me. So they would come and listen to what I'm saying, you know, and eventually it happened that we were recruiting all junior people, you know, 2830 31 and then ensuring that we train them efficiently. But later we realized, if I if I recruit a younger person who just graduated yesterday, from OB GYN, he or she is blank in his mind, or her mind about IVF, they don't know anything about IVF, right? Whatever files, you need to insert in their mind and block it, they will be stuck there. You know, somebody who's practice in IVF, for 1015 years might be a good clinician, but they come with their own baggage that this is what I think is right. You know, this is what I've been doing in my last decade or so. And this is what I swear by. And I will not change whether you tell me that this is good or this is bad, I have not changed my practice. And that's why, you know, if somebody would come for an application, or we can see application comes, somebody says I have 15 years of experience in IVF and wonderful clinician, good business, good outcomes, somebody comes and tells me I have just graduated yesterday with my OBGYN, we'll pick up the later one and not select the first one because you know, we are a rapidly changing organization is what I was doing as a clinician 10 years back, we have changed the complete protocol in today, if I see today, and what I was doing 10 years back is completely different. So one should have that flexibility in their mind to keep adapting to the newer protocols, evidence based medicine that comes in. And I feel this younger Lord, having gone through that process of working with us getting trained with us, following one single protocol. Every time a new protocol comes in, we do a pilot tested at one, report the outcomes to all the people and then say, Okay, let's go and change this protocol from tomorrow morning. You know, because this is better. This is the evidence based reports. This is the pilot that we've done. So the entire culture of the organization has said from day one, that it has to be young people moldable whatever we have taught them, I think I think most of our people would not know the various five or 10 different types of protocols that exist. And if they would just know, one protocol that they've been taught because they had no background about it. I think that's that's the plus point that we gain, recruiting younger people because we were not depending on experienced clinicians for getting patients, patients are being sourced by the marketing function. And we were very confident any clinician, we were trained to get similar outcomes, you know, so I think our work of a trained doctor was being handled by the marketing function and the training function to get more patients and ensure once you get those patients the outcomes have to be good.


Griffin Jones  49:44

There could be a couple of reasons why people don't have one protocol where it's because well, we need older docks in order to have them do their own marketing or we don't have the training infrastructure to bring everyone up to do this one protocol or it could simply be that There are dogs that are set in their ways that and they're not receptive to change. And that could be very difficult and having one universal protocol. What about someone that would say, That's too rigid? Dr. Marty, that's too it's that doesn't allow the clinician to be a clinician at that point. They're just a, they're just a cog in the machine. And it doesn't allow them to provide individualized care to the patient, how would you respond to that?


Kshitiz Murdia  50:31

So Griffin, we we're not saying one protocol, it could be multiple protocols, but one protocol for one type of patient. So we are individualized yet standardized, I would say, you know, for a different type of a patient, young patient, you would use a different protocol for the older patient, you would use a different protocol. But I would not have 10 protocols for my older patients or five protocols. For my younger patients, we do allow some kind of flexibility, but not to a very great extent, I would not say they can choose between three or four protocols, or three different types of medicine, we would maximum have one particular medicine being prescribed for a particular compound. At max very, very rarely, I would say two different types of brands are medicine. So everything is being systematically put in Europe, people, people are okay with it doctors because they are getting outcomes, you know, if something is wrong in my system, in my protocols in my SOP, you will not get outcomes. And then you know, I would also want to change if you're getting good outcomes. If everything is well, why would you want to change a particular protocol. And slowly, we are now getting to a point where we would now be enforcing it to our system to AI EMR, which would be much more intelligent. And we are feeding all our SOPs and protocols into the EMR. So it would keep assisting, keep alerting keep stopping the doctors at any point of time, if they are going in the wrong direction.


Griffin Jones  51:55

And so how would you respond to someone that says that ties my hands too much?


Kshitiz Murdia  51:59

I mean, it's okay. I mean, if there is any protocol that you think is better, let us know we'll do a pilot in your center with few patients and see if the outcomes are good, we are happy to change the entire country on that protocol. We are open to that. But it has to result in better outcomes or reduce the risk of complications to the patient, or reduce the expenses of the patient, then we are open to it.


Griffin Jones  52:22

Let's recap some of this meteoric growth that you've had. So that so you join in 2010. For at the time, there was one center in the western part of India, and from 2010 to 2014, you had that one location, and you're practicing as a as a clinician, there's no second location, second location opens up in 2014. And that's when you start with the awareness camps and starting to grow the marketing. And then by 2018, you had 50 centers, or at least 50 offices. So at this time, is there still one hub? And in the other 49 or so are spokes?


Kshitiz Murdia  53:04

No no majority of them, but hubs


Griffin Jones  53:07

is IVF labs? 


Kshitiz Murdia  53:09

Yes. 


Griffin Jones  53:10

Across the country? 


Kshitiz Murdia  53:11

Across the country. Yes. 


Griffin Jones  53:13

And so what is it today? How many IVF labs does Indira fertility have


Kshitiz Murdia  53:18

this for labs? Well, most 49 or 50, and rest 65 66? Whatever 67 number would be spokes.


Griffin Jones  53:27

Wow. So So somewhere around 50, IVF labs, and then somewhere between 60 and 70 offices in more remote areas where they do everything except retrieval and transfer. 


Kshitiz Murdia  53:40

Yeah. 


Griffin Jones  53:40

And 250 physicians about maybe a little more? 


Kshitiz Murdia  53:46

Yes. 


Griffin Jones  53:47

And how many employees


Kshitiz Murdia  53:49

Roughly 2700 2800 employees? 


Griffin Jones  53:49

Wow, so there was a there was a dramatic growth that that went from 2014 to 2019. It sounds like it was largely fueled by the awareness camps that you were doing that marketing, building the SOP and the training. And then at what point did you decide okay, we need a financier behind this and because it sounds like you were talking to some private equity folks before TA and that it sounds like ta happened in 2019. So, what year was it when you decided okay, we need a financier behind this.


Kshitiz Murdia  54:26

So, Griffin, I think the the requirement was not from the financing point of view because fortunately IVF is a good business to be in the margins are better and then you know, your own internal accruals could fund the the future growth of this interest. The requirement to have a private equity was more from a global exposure point of view, having good governance, good systems, good processes, attracting good talent to your company and then obviously building that solid foundation. You know, as a family as a promoter, we brought the company to one level. Now to go Further, we need some partner who can instill those values, though that culture in the company attract talent, build a solid foundation. And then obviously, we can take it to the next level. So I think that was one of the major requirements. So with the DA investment, nothing came in into the company, it was all secondary money being passed to the shareholders. But if we had a partner who could, you know, structure the whole organization for the future?


Griffin Jones  55:25

Why did you need their help for that? Why? Why couldn't you do that? On your own the culture that normally it seems that's what what comes from the organic side? What do you what do you think you needed their help with?


Kshitiz Murdia  55:37

I think as a as a family, as a promoter, you are not exposed to that global expertise. And, you know, once you have private equity people coming in, they you get to learn a lot on on corporate governance, on structure on sustainability of the business on building a platform, as a family as a promoter, you are very much involved into day to day operations. And I said, the difference between a value creation or a wealth creation versus difference between, you know, looking at your p&l every day, every month, every year on how many profits or much profits you make. So that's a basic mindset difference. And I mean, we've been exposed with deer for the last four years, and now the mindset has changed dramatically. If you were to talk to me five years back, my mindset would have been different. So today's


Griffin Jones  56:23

associate at that time was behind CCRM. Is that right?


Kshitiz Murdia  56:28

They used to want CCRM. till last year, I think last year, they sold it off somebody.


Griffin Jones  56:33

So when they came in, they had a good bit of experience in the fertility space. What things did you say, Okay, we want to do we want to learn from the CCRM way and what other things you say, no, we want to protect this and do this our way?


Kshitiz Murdia  56:49

I think I think there was no technical exchange of information that happened from the CCRM. I think it was the global expertise of tea associates, having worked on multiple businesses across different geographies, and also some experience on fertility business. But I think it's very difficult to replicate practices from one country to another country, and then you know, expect good outcome is the general know how of building a good foundation that helped us to a great extent, I would say if I look back at their partnership, the value and that they have created I think it's it's building out that solid foundation, then building out that leadership team, and developing that culture that DNA, the organization that is very future ready for any kind of growth, it kind of shocks that might come along our way.


Griffin Jones  57:35

There's so much more I could ask you, but we'll save that for a future episode. I'd love to have you back on the show. If you're open to that idea, at some point in the future have any summary of what you're talking about? Or maybe Indira has plans for the future putting thoughts?


Kshitiz Murdia  57:48

Well, we are open to some acquisitions in some parts of the country as well. We also looking at senses to our businesses, which is getting into genetics getting into pathology, we have Axos lot of pharma products, which are directly being manufactured for us from the cdmos. We are looking at adjacent businesses like mother and child as well. We have already started our expansion medicine countries, which is Nepal and Bangladesh and Southeast Asia being a very attractive market. We are very open to you know, having a partner who could take us or help us in that area. I think this is broadly the plan that we're looking at for the future growth. But


Griffin Jones  58:29

Kshitiz Murdia, thank you so much for coming on inside reproductive health.


Kshitiz Murdia  58:33

Pleasure, Griffin, I enjoyed the conversation. Thank you for inviting me.


Sponsor  58:38

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

182 6 Barriers To Automating The IVF Lab, Featuring Eva Schenkman and Helena Russell



What is stopping IVF labs from becoming fully automated? Tune in to this week’s episode of Inside Reproductive Health, as Griffin Jones sits down with Eva Schenkman and Helena Russell of ARTLAB to breakdown the six main barriers to automating the IVF lab.

Listen to Hear About:

  • Why automation isn’t happening in certain areas of the IVF lab.

  • Risk and inefficiency of data entry.

  • Lack of trust that comes from business intelligence software.

  • Lack of adoption of the Vienna consensus.

  • Which metrics are meaningful for safety that don’t necessarily improve clinical outcomes, but are required to improve safety and productivity.

  • Delivery vs operations- what needs to be prioritized now vs. what should be prioritized for the future.

Website: www.artlabconsulting.com

Eva’s LinkedIn: https://www.linkedin.com/in/eva-schenkman-ms-phd-cc-eld-hcld-6121778/

Helena’s LinkedIn: https://www.linkedin.com/in/helena-russell-5aa60214/

Transcript


Eva Schenkman  00:00

They're missing the point that you know I think UCSF did some data where they showed that having an embryo scope in their lab saves them the equivalent of one embryologist time per day. And if you look at the cost of an embryo scope which is probably akin to about you know, one year embryologist salary that is becoming more efficient with these devices will in the long run, save you money, especially now when there is no embryologist to be found.


Griffin Jones  00:32

All of the change that is not happening in the IVF lab we talk all about the automation is coming to the field and seemingly every talk at every conference many episodes on, I want to know why hasn't it happened already? Why isn't it happening faster. And so I explore those obstacles and barriers with my two guests on today's program. That's Dr. Eva Schenkman. She was a lab manager for a number of years to different practices. She has been a consultant. She now runs a program called ART Lab. And I bring in her colleague Helena Russell, and we talk about the barriers to implementing automation categorically. In the IVF lab, we talked about the risk and inefficiency of data entry, we talked about the lack of trust in the data that comes from business intelligence software, if estimates that fewer than 10% of IVF labs have fully automated their data entry with business intelligence software, we talk about the Vienna consensus. Why has there been a lack of adoption in the Vienna consensus again, I asked Helena and Eva just a ballpark how many labs they think have adopted the Vienna consensus. And I'm asking them to do this off the top of their head, but they think it's about half that have adopted some meaningful level of the Vienna consensus. We talk about other metrics that are meaningful for efficiency and safety that don't necessarily improve clinical outcome, but are necessary for improving safety efficiency. And for activity. We talked about this person dynamic between delivery and operations where you are on the hook for doing a certain number of IVF cycles, you're on the hook for serving a certain number of patients, you have to do that to make payroll to keep the lights on to keep the patients happy. Meanwhile, there's the operational systems behind that which are another entity another chore to solve. And those two things are at odds of each other in terms of what is prioritized now in the moment, but what needs to be prioritized and improved for the future and for ongoing delivery. Finally, Helena and Eva say that some solutions are not ready for primetime and boy do they go to town on naming who those folks are? Now they don't try to get them to but of course they go hard and ideas and soft on people as is generally good advice. So it was a constellation for myself, I have to detail what they would like to see from RCTs what they think is missing from solutions that are coming to the via what they think needs to be proved in order for solutions to merit much wider adoption and what IVF centers could do in the meantime to help prove the concept. Enjoy today's episode with Helena Russell and Dr. Eva, Schenkman, Dr. Schenkman, Eva, Ms. Russell, Helena, welcome to Inside Reproductive Health.


Helena Russell 03:19

Thank you, it's great to be here.

Eva Schenkman 03:20

Thank you.


Griffin Jones  03:22

I've finally fulfilled the promise or I'm living up to a promise where I said it was going to create more IVF lab content than I have in the past. I think, this year, we've already done more episodes about the lab than we did in the first three years of the show, combined. So I'm starting to have a rudimentary level of knowledge to where I can maybe start to ask more interesting questions. And one of the things that I want to talk about today is the obstacles behind the automation for the lab. So at a high level, on the show before I've talked about the automation that's coming to the lab, and like to take advantage, speaking with each of you about why it isn't happening faster, and probably have you unpack and give specific examples as we go. But maybe we start at a high level, with just the automation that you're seeing in the lab happening right now that you weren't seeing five years ago, and maybe not even two years ago, what's happening with regard automation.


Eva Schenkman  04:25

Now, one of the ways in which, you know, I've been involved in some of my consulting activities in some of the automation is through data analysis. You know, we spend an awful lot of time in the lab, you know, crunching numbers. And in most labs, we still do it the same way we did 30 years ago, which is, you know, we've usually got two or three different Excel spreadsheets, we've got one for data, we've got one for cryo, you know, we may also be entering something 20 or more, and we used to sit there at the end of the month or the end of a quarter and spend, you know, 234 days to crunch all those numbers. So not only counting the amount of time that embryol Just spending putting in all that data, you know, risking all those data transcription errors, you know, now we've been using things, you know, business intelligence software, like Power BI, to pull that data automatically out of the IVF EMRs, to run that data in real time, so kind of call that real time analytics. So that I see is one of the key ways into which we can save, you know, an enormous amount of time making the labs, you know, a lot more efficient, is on a data analysis standpoint, you know, one of the big talks now with a lot of the meetings or on automation in the lab and efficiencies in the lab, and, and, you know, I think we can talk a little bit more more about that, what the roadblocks are, you know, to those. And, you know, to a long way, I think a lot of the roadblocks are One is cost, you know, a lot of these devices, things like, you know, an embryo scope, for example, are very expensive. And, you know, a lot of physicians or a lot of practices expect to see, oh, I'm gonna get this device, it's going to increase my pregnancy rates, oh, it doesn't increase my pregnancy rates, well, that I'm not investing that kind of, you know, money into it. But they're missing the point that, you know, I think UCSF did some data where they showed that having an embryo scope in their lab saves them the equivalent of one embryologist time per day. And if you look at the cost of an embryo scope, which is probably akin to about, you know, one year embryologist salary, that it becoming more efficient with these devices, will in the long run, save you money, especially now when there is no embryologist to be found. You know, and I think some of the other issues I see with the automation is things are rushed to market quickly, you know, at at a very high price, and they don't necessarily have you know, a lot of the data behind it yet, that you know, that it is going to be you know, just just to save for just the same as a senior embryologist. So I think kind of got, you know, a couple of issues there, you know, between the cost and, and the efficiency, and, you know, making sure that you know, that we can get get current staff to adopt, you know, this new technologies,


Griffin Jones  06:59

because you give me a couple of different avenues that I could further explore. Let's start with the spreadsheets. You mentioned, having two or three Excel spreadsheets previously, for which you need for your data analysis. What were they what what were their roles, those those spreadsheets and the information that they contain


Eva Schenkman  07:19

everything from, you know, you're doing your pregnancy rates, your competency assessments, also your CRO inventory, you know, we typically, for the most part, still keep paper worksheets in the lab, very few of us are using, you know, tablets or have gone paperless. So, you know, we've got that paper, you know, we're either scanning that paper into an EMR or, you know, retyping that data into an EMR. And then typically, a lot of the EMRs, don't do data analysis very well. A lot of them don't have reports that follow the Vienna consensus, you know, guidelines. So we're then keeping separate spreadsheets, so we're putting things into the EMR, putting things into, you know, Excel spreadsheet for data analysis, and then typically having a third sheet for, you know, cryo inventory. So we're entering everything, you know, typically three times, and then taking having somebody you know, typically higher up, then do all of that data analysis, like I said, usually typically the end of the month, sometimes at the end of the quarter,


Griffin Jones  08:17

how is QA done in this instance, when you have three different sources of information, but they're all in different places? How, how is QA done so that the duplicate of information is correct, because anytime you have information, different sources that isn't uniformly exported, you always risk you


Eva Schenkman  08:37

typically an Excel worksheet, you hope you catch it, there's not really a lot of a lot of formulas in there to kind of automate to to pick that up. You're always gonna get data, transcription errors, some of the things like Power BI can can pick that up for you. But I think, you know, honestly, a lot of times it gets caught when you're giving a patient data off of your cryo Inventory spreadsheet and a patient, you know, or nurse, correct shoe, you know, will will that's, that's wrong. That's not what we had, you know, so that that is a problem, you know, with data entry errors, is we really don't have a good mechanism to ensure that the data is accurate.


Griffin Jones  09:14

So when you have three sources of info like that, you got your spreadsheet for cryo inventory, you're scanning into the EMR, and then you've got a separate spreadsheet for the data analysis. There generally isn't like an overarching QA for the data entry to make sure they're all uniform. Now, okay, so even without regard to efficiency, there's still there's a risk there.


Eva Schenkman  09:36

Yeah, absolutely. You know, your data is only as good as the information you're putting in.


Griffin Jones  09:41

You mentioned that is an area where clinics are starting to automate more and those spreadsheets are being supplanted or that's something that you envisioned in


Eva Schenkman  09:51

the know there actually is is a few systems out there. Several of the EMRs have been using business intelligence software either through Tableau or through Power BI and linking those with their EMRs to that automatically pull that data out of the EMR. So as soon as you've done your first check, you know, as soon as you've done, you know, your, you know, your observation or the pregnancy data is entered in, it's pulling it into those Power BI sheets. And those not only that are automated, but they can even be set up to then watch you when there's a problem. So they can send you notifications that, you know, Hey, your XC three P and rate is starting to creep up. So you can, you know, definitely not only from an efficiency standpoint, but also from a troubleshooting standpoint. So I know, you know, recently one of the media companies had an issue with with some oil, for example, you know, and that, you know, typically tends to take a little bit of time until you're able to pinpoint what the problem is. And you know, the hope is that these automated systems would be able to pick up on something like that much quicker than you'd notice by eye or, you know, you got to wait till the end of the month, you know, obviously, something's killing all your embryos, you'll notice that pretty quickly, but let's just say you've got, you know, 25%, drop and blast conversion rates, that may not be something you pick up so easily, maybe you had some bad patients in there. But you can use a lot of that business intelligence software, it's been used by the, you know, financial industry and other industries for for years, you know, now we can kind of harvest the power of that, and and use for the IVF labs,


Griffin Jones  11:20

do you have even a ballpark guess, of what percentage of IVF labs are now automating their data entry with business intelligence software?


Helena Russell  11:30

Automating? I'd say, single digits?


Griffin Jones  11:33

That's a very, very low, yep. What's stopping it from being at 90 100%?


Eva Schenkman  11:39

I think one is trusting in the data. Two is, is, you know, we, for as much as we like to think we're ever changing, we don't actually like to change that much. You know, we don't want to let go of our paper worksheets, we, you know, this is, this is what we've done for 30 years, you know, we don't want to make mistakes, and what we do we know that, you know, an Excel spreadsheet, you know, as long as it's not, you know, sorted wrong or tampered with, you know, it will get you the, you know, the data that that you need, you know, a lot of the EMRs aren't necessarily don't necessarily have the best fertility modules. So, you know, even, you know, a lot of people in the lab, they're, they're still using the paper worksheets, and they're only scanning in their sheets. So one is, is, you know, if you're going to use something like Power BI or Tableau, you really have to have a dynamic EMR, to be able to use that with so. So that's something a lot of the clinics struggle with, you know, and I think just just trusting, trusting in the data is a bit of a learning curve, you know, to to get going with it. And, you know, I think slowly it's, it's starting to come come about, but, you know, slowly,


Griffin Jones  12:46

by the way, Helena, anytime that you want to jump in, I tend to just riff off questions, because I


Helena Russell  12:51

just want to say a couple of things to, to kind of, you know, kind of chime in with Eva, one thing, that's what's really challenging is learning curve, because it's not just trust, it's taking somebody who works with their hands, and putting them into a situation where they're going to have to be working with computers more. And that can be a little daunting. But again, having the right tool and the right support from that tool, helps us something else that even just said, is that they're not, not all of these EMRs are created the same. And that's true across healthcare industry, in general, you know, they're very unique, there are so many out there. And they do different things differently. And so there may be some that are a little bit better for gathering all the information that needs to be gathered, and also to be flexible enough. One thing that you may or may not realize about IVF is that not all IVF centers do things exactly the same way. So you have to be flexible. And the learning curve is one of the one of the things that I think is challenging for people and trust, like Eva said, another way of automating that kind of tails into EMRs. And specifically EMRs built for IVF is witnessing, which is an automated system these days with barcode reading or with radio frequency. And even might want to chime in on this one as well. She has a lot of familiarity with these. And those are also tying in with some of these IVF databases, or electronic medical record systems. And again, pulling a lot of really good valuable information from the lab into that system helps with once we get to that point where we can do the analysis via you know, Power BI, what we can then do is really target quality control, quality enhancement, and quality assurance.


Griffin Jones  14:56

Let's stay on that thread for a second before we get into workflow variance and And the barrier of change. You mentioned one of the issues apart from that is trusting the data itself. So what is the cause for mistrust and data? Or what is the risk of inaccurate or incorrect data in using business intelligence software for data entry,


Eva Schenkman  15:18

when you're pulling data from from an EMR, you know, one of the problems is, these EMRs are all structured differently, you know, they're usually large back end SQL databases, they may not be, so you can't take, you know, three different EMRs take the same Power BI software setup and plug it into these three different systems, they won't work, you know, so these things have to be customized, you know, unless it's something your EMR is already offering, they, they would then have to be customized to each setup. And a lot of it is just in that analysis, knowing you might have two or 3000 different fields on the back end, to pull from, you know, how are you? How is each lab recording that data? Where are they? Where is that data sitting in the SQL? databases for analysis? I think some of it might be generational, you know, I think, you know, the first first generation of embryologist, you know, even though we're we're, you know, we are pretty good at using computers, you know, we, for the most part for the last 30 years have done everything on paper, have done everything, you know, simply the second we have to trust, setting up those scripts and setting up something to to the IT department, you know, it's these things are very difficult to validate. So it's a lot of time, and one of the things we don't have right now is a lot of time in the lab. So I think part of that is, is having the time to validate these systems to trust them, it would be very hard for company to come in to develop, you know, a Power BI software, that's, that's applicable to all EMRs. Because the EMRs are all structured differently. So they need to be done, you know, on a customized or bespoke, you know, level between between each system. But I think it's just as I said, I think it'll be different with this new generation of embryologist coming through, I think they expect it, you know, they practically live with a phone, you know, in their hand, you know, I think they're going to be a bit more comfortable with with having this data. Automated?


Griffin Jones 17:11

Tell me a little bit more about what you mean, by the time it takes to validate systems? Does it mean to like pilot the program to check the…


Eva Schenkman  17:20

Yeah, you know, I'm actually involved with one, you know, right now looking at at some of these, these automated reports, and I have to go into the EMR and I put in test cycles, and I'm putting in, you know, different complicated ones with day one xe or with late for some with thaw biopsy, refreezes, combination cycles with fresh and frozen eggs. And all of these data sets are stored in different tables in the back end of the CMR. So that I have to sit with the IT people and structure each of these queries. And, you know, we tested on these cycles, and, you know, these, how do you tell an IT person, you know, when they're doing a competency for, you know, good day three cleavage rate? You know, for example, you know, what does the word good mean? You know, if you asked, you know, for embryologist, you're gonna get five different answers, you know, and that's part of why, you know, we rely on things like the Vienna consensus, you know, as a standard, you know, guideline to go through, but then, you know, each and every clinic, we roll these things out to, has to validate it on their own, because none of us are doing recording data the same way, you know, there's, you know, we all record it a little bit differently, we're all using different templates, we're all using, you know, different embryo grading criteria. So I think that's part of, you know, a bit of a problem with it, you know, I think but, you know, as clinic start to see the benefit of these systems, I think it'd be easier and easier, you know, we get these things validated, we get a couple of hopefully, key key labs, you know, incorporating them into their workflow. You know, I think we'll, you know, we'll kind of get the message out there, that the systems are, you know, are reliable or trustworthy. And, you know, that'll go a long way to really making the labs, you know, more efficient. Everybody's talking about, you know, lab on a chip and everything else. But, you know, I think, you know, when you're embryologist are spending a significant amount of their time being admins, you know, hand entering data is still using paper worksheets. Were a long way away from talking about, you know, lab on a chip.


Griffin Jones  19:18

How much chicken and egg is happening here, like, if part of the reason why labs are slow to adopt the technology, they're slow to validate the systems because there's so much variance in workflow, people report data differently, they grade embryos differently, how much of so that's the barrier, but it's also the result, isn't it? Like if you had the universal systems implemented, that you might have a more universal way of recording data, you might have a more universal Is that happening?


Eva Schenkman  19:51

We have the Vienna consensus, you know, the paper that was written for KPIs. I think that goes you know, along A great deal.


Griffin Jones  20:01

Okay, what is stopping people from categorically adopting this Vienna consensus across all labs?


Eva Schenkman  20:10

I think for the most part, it's been very well, you know, received, I think it's just it's that the woods that way, we've been doing it for 30 years. You know, it's, it's that belief, it's, it's worked for all this time, you know, this is, you know, in that belief that, that, you know, we're kind of all homegrown cooks in each of our labs, that, you know, we kind of, we kind of do it our way, these are the KPIs that, that that worked for us, there are still some labs that are doing d3 biopsy, you know, as opposed to, you know, blastocyst biopsy and slow freezing, it's just that ingrained, you know, because we don't want to make mistakes and in what we do, so in some ways, we're very reluctant to try new things. And, and part of that comes with doing it the same way it's worked, we don't want to change it, but and


Helena Russell  20:54

so much hinges on it, right? Yeah.


Eva Schenkman  20:59

And that first generation of embryologist is retiring. They're leaving the field. So, you know, I think it's, it's, it's important to, you know, this new generation, they're not going to sit there for the, you know, the amount of hours and hours and hours that we spent typing into three, you know, three databases, they want to enter things on a tablet, you know, they don't want to enter things on on paper and then transcribe so, you know, I think there is a lot of push from, from these newer embryologist to to automate things, you know, and, and hopefully, you know, we'll get some significant changes. They're


Helena Russell  21:31

more comfortable trusting the data, as Eva has said,


Griffin Jones  21:35

what percentage of labs is, if you can even ballpark it? Do you suppose have adopted the Vienna consensus to? If not to the letter, you know, 90%?


Eva Schenkman  21:46

I'd probably have to say, maybe, what do you think Elena, close to 50? Probably


Helena Russell  21:53

I still they're not accepting all of them. They're probably focusing in on a few Don't you think? Eva?


Eva Schenkman  21:58

I think so. I'm still surprised how many lab people I speak to who haven't heard of it. And, you know, as I said, each one typically has their own KPIs.


Griffin Jones  22:06

Thank you, Eva. Now, I don't feel as dumb for asking.


Helena Russell  22:08

Yep. It's unfortunate. And I think it's a lack of communication in our field. But I also think that what we're doing is very difficult. And so the challenge is making sure that we continue to be able to produce what it is our patients need. And to meet our patients needs. I mean, there, there's, there's no excuse for failure. And so when you have something working, it's difficult to hear what somebody else is saying, if it doesn't mean an improvement, which I think you've kind of hit on earlier, unless you can show a, you know, a positive outcome. And it may be that they'd rather spend that extra money to have somebody do something in a less efficient way, then trust in something that may not may or may not give them the outcomes that they are looking for. Yeah, is


Eva Schenkman  23:06

it’s difficult to trust in the scripts that are written by, you know, by someone with a computer background that, you know, you as an embryologist don't really understand. So as I said, that's why the validation of it is so important, get them seeing that this data is accurate, and is pulling correctly. And, you know, I think, you know, to be able to have an automated system like that, then alert you, not only when something is out of range, but as deviating towards being out of range, I think will be you know, will be invaluable. And, you know, this, you know, one issue that recently developed with oil is now resulting in a class potentially, you know, class action lawsuit. So, I think, you know, anytime we can develop something that would pick up on these things, not only tell us our what our pregnancy rate is and what our our individual embryologist competency rates are, but to be able to then alert us to any troubleshooting issues in the lab, that we don't have to wait six weeks, you know, now we see something in our data analysis. Now we have to try to figure out, you know, figure out what it is, you know, that's where we're using AI is also going to help at some point, you know, with analyzing this data.


Griffin Jones  24:11

So I'm understanding if there's not a clear clinical outcome that lab directors can see of in terms of success rates, that there often isn't the impetus to impose a change, and I see the agents working against change. We've done it this way forever. It's worked this way forever. We have a big variance in workflow from one place to another. So just because it worked for these guys over here doesn't mean that I know that it's going to work over here, but at this point, why isn't the shortage of embryol embryologist and the constraint on embryologist time enough to have made a bigger catalyst for change? seems like to me it seems like okay, if success rates are equal, but I can get back an embryologist day. Every time that we use this solution, or I can get back this many hours of embryologist time, why is that not enough of a catalyst to be seen way more automation than we're currently seeing?


Helena Russell  25:22

Part of it has to do with time, it takes time to train somebody to do something new. You know, if you're so overwhelmed in your lab or your IVF facility, and you don't have enough time to train a new person, you don't have time to learn something new, don't you think? Eva?


Eva Schenkman  25:44

I think so. And I think it's just that you know, exactly that you don't have time to train something new, it's that chicken and egg, you know, scenario, again, you know, I'm so overwhelmed, I not only have time to not train somebody, and then you say, Oh, well, you know, get this piece of equipment or whatever, for automation, there is going to be a period of time where that, you know, system is going to actually take you more time, until you you know, you wreck it, you know, you're able to be proficient at it and you're able to, to realize its efficiency. And, you know, not all people have the patience for that much time for adopting it and the cost, you know, all of these, these automated systems are very expensive. So getting physicians in groups and practices, it's easy to say, I need another embryologist and they'll pay, you know, six figures. Plus, for an embryologist who see a body sitting there, you know, to pay six figures plus for a piece of equipment sitting on the counter, you don't see the efficiency savings as easily as you see another body sitting there. So I think that's part of it. And without them seeing, you know, like, as I said it, you know, I go back to time lapse, you know, they there was just, you know, paper recently that, you know, basically is, you know, we shouldn't be, you know, looking at time lapse, because there's we didn't see an improvement in pregnancy rate, but you're missing, you know, the picture of it, you're missing, you know, the safety of it, you're not having to take the embryos out to look at them, you can monitor embryos remotely, you know, so if there is, you know, more COVID outbreaks or another pandemic, you know, you can check fertilization from from home. And, you know, just that


Griffin Jones  27:18

you could centralize embryologist could knew or at least part of that workflow,


Eva Schenkman  27:23

you could do you have offsite lab directors could monitor things remotely, they can log in and look at the embryos look at how they're growing, you know, pull the data, you can see these Power BI apps, you can see all of your data on your mobile device, you can even see the images of your embryos on your mobile device. So I think it's, it's, it's, it's that cost barrier, but it is that learning barrier, that it's just not something new that we've done. And, you know, I think you'll I think next years, there'll be some workshops, at some of the meetings that are going to be focusing on future of technology and innovation, and where where things are going to be, but not just theoretical, but actual practical, what's here, what's now you know, what can we kick the tires on now, and part of that is, is training and having these new innovative systems launched at the at training centers, and having a rail just come in and use them because nobody wants to practice on a real patient. You know, you need to be able to have a place that's comfortable, that you can go in and you know, learn this in an environment that's not stressful, you know, not while you're you're trying to, you know, to do real patient samples, that you have a place to get comfortable with these devices and, and to you know, learn how they work.


Helena Russell  28:36

And we're all monitoring is integrated. And I mean, yeah, looking at your incubator, your temperature, your co2 level, your oxygen level, looking to see if your liquid nitrogen tank is got enough liquid nitrogen tank, liquid nitrogen in it, making sure your refrigerators are performing up to par. And having those be part of your automated, automated integrated system so that you literally have every function that you would normally assigned to possibly, you know, an intern or a novice embryologist, somebody who's a junior who's just coming in. Instead, you can have continuous monitoring, which I think is extraordinarily reassuring. Probably there's a role for someone or company out there to help clinics bundle and to become efficiency experts. I think one of the things that our training center does is helped expose new embryologist and even in workshops where we're opening up our center to experienced embryologist to come in to have one or two day workshops, they will be exposed to those kinds of integrated systems as well. And you know, a lot of it has to do with you know, I can I can hear about it all day long. I can read about it all day long. But if I can touch it, and I can move the dials and nobody's sample is going to get hurt by that. And I can actually download an app and do it on my own phone or my, you know, my iPad, while I'm in this Training Center. You know, the


Griffin Jones  30:13

exposure that you're talking about in the training center accounts for some of the issues, the distrust in the data, the lack of familiarity, the validation of the system counts, for some of them. Some of the things that it doesn't like, what you've been talking about is something that I've been obsessing over with regard to my own business and business in general. And I think we can apply it to the IVF lab, and that is delivery versus operations. And often when you hear business books, or you hear business talks, operations, and delivery are almost used interchangeably, like delivery, meaning the fulfillment of the good or service, which we've sold or promise and operations is really the system behind it. So we're roofers, our delivery is we're going to have a new tear off roof on your house by the end of April. That's the delivery. And we have an obligation once that roof is sold to fulfill that deliver, you could use delivery and fulfillment interchangeably. But operations is the system behind that delivery. So delivery is getting the roof on the darn house getting it done by the date, we said we were going to get it done by but operations is what types of materials we buy the workflow behind it, who we assigned to the job, how the job is assigned and accounted for and reported on the QA that comes after it the what what we automate or don't automate. And, and all of that is operations. And there's a tension between delivery and operations, because you have delivery obligations that you have patients cycling through, and you have a finite number of embryologist that can work on those embryos, while those patients are being served while you need to make this institutional change at the operational level. So how do you solve for that how, in this specific to the IVF lab, how do you begin to relieve some delivery obligations, while investing in the operations that will ultimately result in a virtuous cycle.


Eva Schenkman  32:35

Part of what we have here as opposed to just also having, you know, kind of a training facility is is you know, our training facilities a fully functioning mock IVF lab. So one to have all of these different systems communicating here. So that when people do come and try them, it's not just trying one piece of it, it's kind of seeing, you know, the entire system working as if this, this was a functioning lab, the other thing we have to convince them of is, is you know what to do when it goes down, because that's one of the most common things, you know, I hear that if we're going to be entering things on a tablet, or we're going to be entering things, you know, when our mobile device, you know, data patient data is potentially going up into the cloud, you know, nobody trusts that. So, you know, it's, it's the redundancy that's built in, you know, are we going to do you know, backups to, you know, to, to our local desktop, or we're going to print out, you know, a daily report, because what are you going to do when, you know, there's a hurricane that comes through retreating, like, what are you going to do, if a natural disaster comes through, I always have my paper, I always have my paper chart, you know, but there's that trust and what you can't see. And you know, we're all used to the internet going down the Wi Fi going down. But as an embryologist, you still have to do your job. And if everything is up in the cloud, and you come in, you got no Wi Fi, you know, how do you know what patients to do the first checks on or how do you know what patients to, you know, to do the freeze on or which embryos to thaw. So, you know, we do need to get better at that, you know, ensuring you know, what we're going to do from redundancy standpoint, to be sure that those concerns are addressed. And, you know, I think is, is, you know, manufacturers out there, we need to play a bit better in the sandbox with each other, and, you know, working on ways to get these systems communicating better with each other, because each one, you know, is kind of fine on its own, but there are these own little islands that aren't interacting very well with each other. They're very clunky, you know, not not not very quick. So, you know, we do need a lot of development still in those areas. But and I think, you know, the only way is to have kind of testing labs, you know, where where we can kind of kick the tires on these things and bring embryologist in to use them?


Helena Russell  34:40

Well, just to add to the you know, a lot of what we see in other industries, like the banking industry, a lot of what they do is done in the cloud. And you know, they have to have their very, very strict rules and regulations and other health care branches of health care industry. These people are doing a lot of commerce in the cloud, a lot of data storage in the cloud, and those redundancies have to be backed up by a robust IT support system. So they do exist for some of the systems that, you know, we've been talking about, you know, sort of loosely, but the really good ones are going to have that kind of support and structure so that you can, you know, assure those who are using it, hey, that information is going to be there. And they have to have an offline, you know, like a holding place at their own facility, a server that that information can be stored on,


Eva Schenkman  35:36

I still see a lot of doctors practices, their servers are in a closet down the hall. Yeah, and, you know, a lot of clouds. Yeah, that, you know, and, you know, we don't really hear it's not really openly discussed, but you know, we get a lot of clinics, there's a lot of clinics that are hit with ransomware. And, you know, a lot of that is kind of kept swept under the rug. And that's something that we need to, you know, why why do we not have a strict regulations as the financial industry, as far as how we're keeping this data, you know, where we're keeping this data redundancy,


Helena Russell  36:05

if you're thinking about automating, and you're thinking about going down this road with an EMR ask the really important question. And that is, how is this stored? What is your security structure? How is it done and who's handling that? Because, I mean, you have to, you have to have a very robust system, and it has to be redundant, can't just be stored in one place and must be stored in multiple places. And how that is done is actually critical, not only to the, you know, the security of your data, how you trust your data, the validation of the systems, but also whether or not you can move forward and practice one day, you know, if somebody holds you for ransom, you're stuck.


Griffin Jones 36:47

Well, that solves for the issue of redundancy, it solves for a lot of the issue of implementation. But a lot of what you described is still the challenge of delivery versus operations. A lot of the reason why people have their server in a closet down the hall is because they've been so busy fulfilling delivery commitments, meaning seeing patients doing retrievals doing transfers, and all of the lab work on the other side of that, that they have not had the time, money energy, to focus on the overall operation systems, you happen to have a program that takes care of a lot of the risk that allows people to visit allows people to do this without putting their own things at at risk or and taking their own, you know, having to test everything within their own system. But they still have to say, alright, well, I've got you know, maybe I've got four embryologist and I need seven. And so how am I going to send you one of my foreign biologists when I'm already half staffed? And, and so how do you how do you begin to solve for that


Eva Schenkman  37:56

one of the things we've been doing is offering you know, several, kind of intensive lengthy courses a year, you know, we, we, you know, and Elena primarily has been going out to to the universities we have someone who's also worked with us doing you know, on tick tock, you know, doing tick tock videos of getting those students out here to, you know, for training, so they typically come to us for for 10 weeks and we teach them everything from Andrology to biopsy, you know, we don't expect that these these these, these new embryologist could go back to their clinic and you know, be doing biopsy on day one. But you know, the typical in the old school apprenticeship style, it would take between two and four years to train one embryologist then we're losing embryologist at a much quicker rate than we can replace them. So if not only, you know, the training school that we have, but the other ones that exist in the country. You know, we are we believe that we're able to now get that training, once they're at the clinic down to under 12 months, so that we can speed up their training. So if you've got four you need seven. Well we can send you you know, you know, we're churning out embryologist, every embryologist that has been through here. I know everyone else had been through, you know, the, you know, one of the other firms California has had a job offer, you know, they're all you know, getting employed. And you know, we need to to, you know, bring through more embryologist and you know, and replace somebody even even a faster clip and that's the only way you know, we can't any longer do this, this apprenticeship, where it takes two to four years to get one new embryologist it's, it's not it's not sustainable. You know, we need a better way of of bringing them bringing them up, bringing them through quicker getting them trained. And you know, the style that we do it here which is very intensive, you know, they spend probably close to about 500 hours, you know, doing every literally every procedure and you know, over the course about two and a half months,


Helena Russell  39:52

hundreds of times they do each procedure hundreds of time. So what we're doing is set adding them up to make it easier for those who are doing the training on site in the IVF lab, making it easier for them to get the embryologist they need. I do think that part of the operational pushback is there needs to be kind of somebody who could bundle I really do believe that there's a there's another role out there for it, an IT biologist or something, you know, somebody who could go into a lab and do a consultation and say, you know, an EVA really has that kind of perspective, she may not be the IT expert, but she has, you know, a really good perspective on, you know, hey, you're doing this, this, this, and this, here are some products and, you know, we can put all these things together and deliver them to you. And you know, here's our IT redundancy expert, you know, can come in, look at your system right now, and say what needs to happen? And what tools can we bring in here that are going to meet your needs? What need do you have? Do you want to do all your quality control remotely? Do you want to do your embryo analysis remotely your embryo culture analysis remotely? Do you want to bring all your data together so that you can meet your KPI with a click of a button, review your your KPIs, and then bring all of those things together, and act as a liaison between all these different groups? Because it is a little mind boggling when you look at what is happening in the IVF field. And you have you know, this automated system and this automated system and this automated system and this automated system, how do you bring all of those things together? That's the challenge. And not everybody's going to want all those things. So how do you do that? That's that part of that operation could be someone who's an expert at all these different things, helping to give advice, consulting, and charging a fee to bring it all together for them and stitch it together.


Griffin Jones  42:01

Helena, you were talking about the challenges in having so many different automation solutions, one solution to that problem of having so many is having a consultant or an umbrella solution of some kind that can bring them together. How much of the problem is also those solutions not integrating with each other not integrating with the EMR? How common is that


Helena Russell  42:28

it's happens all the time. And Eva spoke to that earlier that people in these different realms need to play well in the sandbox, they need to be able to open up their their systems a little bit, so that they can speak to each other push and pull data, because a lot of times you'll see, well, one company will let you do one thing, but not the other. And you need both. And, you know, I think it's a little that's an operational hurdle. And again, an integrator, somebody who really is quite savvy and knows, you know, how to communicate with these folks could hopefully bring some of this together, I know of, you know, at least one company who's doing things like that. I'm sure there are plenty of others that are attempting that, you know, it's it's a daunting task, we know that we know it's very difficult to change. But one of the things that the light at the end of the tunnel, you're never going to stop changing. And IVF though that's just plain and simple, it, you're not going to reach a pinnacle and say, Oh, we're done. Now we've reached the pinnacle, because something new is going to happen down the road, something new, some new way of doing analysis. And so you're going to always have to change you're going to have to learn to live with that. And like Eva has said some of the newer generation, they're used to maybe looking at things a little differently, maybe not so much always changing. But at least the electronic aspect of it doesn't seem like it's so that was daunting, not as daunting not as as much of a trust issue. Now I can't trust my computer gets viruses, right, or I can get malware. So I think that, you know, if you if you have the right systems and the right checks and balances the right security systems and redundancies, as we've said, you will begin to you know, get over that hurdle. That's one of the biggest ones.


Griffin Jones  44:20

But if they don't integrate, aren't we back to the same challenge of the spreadsheets?


Helena Russell  44:25

A lot of them are integrating. Yes, we are if they don't integrate a lot of them are seeing the handwriting on the wall. I think Eva, wouldn't you agree?


Eva Schenkman  44:35

I think so. Now,


Griffin Jones 44:37

seeing the handwriting on the wall and that they're not being adopted, if they don't integrate


Helena Russell  44:42

They’ve got to make themselves a lot more malleable in order to be adopted. Like you just said, if if we're trying to show people how to use a KPI and the system that is is giving you your best data and is not you No handing it over that you have to actually export it and upload it a different way that may be not as user friendly, you might do it. But if somebody else down the street will integrate, guess who's gonna get pot?


Griffin Jones 45:14

So there might be a market response that forces people to integrate more you had in the beginning of the conversation, you alluded to some solutions, maybe not coming to market, but not having the scientific proof that they have a great benefit. What are some examples of that?


Helena Russell  45:36

Well, I think even would agree that there are some products out there that we need to more closely scrutinize and names. I'm not going to do that. But I will say that their artificial intelligence base, but the the issue with some of these is, you know, the gold standard in scientific medical research is the randomized control trial. And some of these products, they may have them in progress, but as far as I know, not really have published as much as they should, or at all. And so one of the things that I think we need to as a scientific community, which is what IVF is a part of, is that before we fully buy in, or spend an awful lot of money on something, that I mean, maybe we volunteer to be part of that study, you know, if you're an IVF center, and you're interested, you know, say, okay, all I'll be part of this study in order to help advance this field so that we'll know one way or the other, what they're promising may not be that we have better outcomes, necessarily, but that we might have more efficient outcomes, which might lead to better outcomes, because maybe your embryologist won't be so incredibly stressed out all the time, because they can't function because they can't get all their work done. Because there's not enough of them. And this automation could become part of the workflow that holds an answer for them, at least part of an answer.


Eva Schenkman  47:13

And I think that I agree with Helena, you know, the biggest issue is, is you know, especially, you know, right now, you know, the flavor of the month is kind of anything AI. And you know, each of them have some some papers coming out that they're showing that that, you know, this system is the best or that system is the best. But there's really a lack of well, plans. Well, well, rigorous setup. Yeah, what very rigorous those randomized controlled studies. And that's really, because what happens is people that adopt it, and they don't see the same benefit in their hands. So there's a big distrust of it, when you have for profit companies, who are then also sponsors of these papers, we're putting out data saying that this is the best thing ever. And then when somebody pays the money and adopts the system, they're not seeing, you know, the same, you know, Return, return to there. And so, you know, I think, you know, that's probably the one thing in this field that that I think is hurt us that we don't do, you know, as many well planned RCT studies, that, you know, we do a lot of retrospective, a lot of, you know, prospective, but not necessarily a gold standard, you know, stuff, which is hard to do.


Helena Russell  48:22

I mean, in IVF, it's very difficult to do that. Now, it's very difficult to do certain kinds of randomized control trials, because you do not have, you know, that many chances for fertility, in many cases who are coming to you for treatment. You know, if you're going to do a randomized control trial, it's got to be planned in such a way to limit the harm or potential harm for the patient. What's harm harm is, maybe they didn't get pregnant. And so, you know, in these cases, when you're looking at artificial intelligence, as long as you have a good check and balance, like you're having, you're having your own technicians review, and re and, you know, respect what's coming out, but review what's coming out of the AI. And make sure that well, whatever it is, it's telling you, you have the human aspect that you've learned to, you know, know, you know, and love, and you trust, then, you know, oversight is good, but what does randomized control trial mean? And what is blinded mean? Because a lot of times bias, unfortunately, you know, enters into these things and how do you create a study where there's limited bias, meaning that you're not overtly influencing the people who are conducting the study? The doctors, the even the patients, and certainly the embryologist, how are you ever going to blind the embryologist? Probably not never, you're probably never going to blind them because they're going to have to keep the numbers straight. Somebody has to protect the patient's embryos and make sure they really truly understand they know this is embryo 1234. And this is embryo 3456 and make sure everything is working properly. So blinding, the embryologist is almost impossible.


Griffin Jones 50:07

Which RCTs? Would you like to see happen with regard to AI companies entering the lab space? Like, can you detail what you would like to see an RCT or a couple of RCTs?


Helena Russell  50:18

I mean, even you talked about this the other day with the AI that you were thinking about that, that I think one of the things that we need to see is more numbers, also consistency and how the training database is working. So how you build that artificial intelligence is by having, you know, a large enough number of input and outcomes, you know, so you have something that you're observing, right, and you're applying an algorithm to it. And then what comes out the end is, hey, do it this way, or, or select this embryo. And so if you have a large enough database, you could potentially apply that one of the biggest problems that we have, is applying it across the entire world, probably not doable, because in each and every lab or each and every IVF. Center, there may be some variables that we really have no control over, that we have to kind of focus in on that particular lab and having enough data to have an artificial intelligence algorithm built may not be possible on a center by central basis. So some of these things, I think it takes time to develop the algorithm and then apply that to a randomized controlled trial, where you're looking at either isolating the artificial intelligence and doing it with sibling embryos, for example. So you have to have a special population of patients who have enough embryos that you could put them into different systems and compare them, or potentially looking at, you know, larger populations, if you don't have those sibling embryos to look at, you could look at groups of individuals in those two different, you know, isolated, different ways of producing the embryo, for example. So it goes beyond what we're currently doing in the lab, which is observational, when we even when we look at time lapse imaging, we're looking at changes over time that those are very interesting markers. Because you could see slow development versus fast development versus abnormal development. And you can see all that in a time lapse imager, this is something that you could never see as a, the traditional way of analyzing embryos to pick for transfer is a, you know, a one, a particular time point. And looking at an individual, you know, time point is, is not as superior as looking at, you know, time time points throughout the developmental process over the five to six or seven day period, that we have them in culture. And what Eva's talking about is even more specific and more precise. And that is going after those molecular markers, where you look at gene regulation, you know, those kinds of subtleties are almost impossible to you may not see anything, but and they made the embryo may be developing perfectly well, you know, it's just looks like a normal embryo. But when you actually look at the molecular profile, and look at the genes that are upregulated or downregulated, compared to the perfect environment where you can't replace something like that, you know, and and in past times, some of the things that people have looked at are metabolomics. I don't know if you've ever heard that word, but it's okay, the embryo is growing, and we're looking at metabolites of growth, and you siphon off some of the culture fluid and you look to see oh, is it metabolizing? Well, but actually looking at gene regulation, and and looking at markers that are very fine detail of the health of an embryo could be a potential answer.


Griffin Jones 54:15

I appreciate you both giving these so much insight into the different obstacles that are inhibiting automation from fully taking the IVF lab by storm. How would you like to conclude with regard to what needs to happen in order for automation to take its full rightful place in the IVF lab?


Helena Russell  54:37

I think what we need to do are some very detailed studies, where we look at how the impact of these automations on you know, first adopters, you know, there's always going to be a group of people who say, I'm there with you, I want to go automation all the way I want to do these things that are going to assist us in in prevailing and thriving and And moving forward, those first adopters should be studied. And efficiency should be studied, we should study all aspects of, you know, their turnaround time for troubleshooting, they're, you know, catching things on the on the fly when there's a, you know, a detail that's out of place for their QC, their daily Qc is messed up and they get an automated announcement. And, you know, there are people who are malleable to this, you know, they will be early adopters. And so those are the folks that we really need to study we need to present at meetings, we need to maybe create the perfect training environment like we have here at Art Lab, where you can bring people in, expose them to this integration and say, Okay, this is how it could work in your lab. You show them something, and that barrier is may not be eliminated, but it's gonna come down a little bit.


Griffin Jones 55:55

Helena Russell. Eva Schenkman. Thank you both so much for coming on inside reproductive health.


Sponsor  56:01

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

181 Increase Your Worth: Fertility Nurses’ Negotiation Strategies, Featuring Dayna Hennessy, COO of Extend Fertility



Do you know your worth as a fertility nurse? How strong are your negotiation skills? Griffin hosts guest Dayna Hennessy, Chief Operations Officer of Extend Fertility, to discuss her tenacious journey from nurse to executive, and how you can learn from her experiences.

Listen to Hear:

  • The merits, and lack thereof, of getting an MBA. 

  • The highlights of Dayna’s experience to get to the position of COO of Extend Fertility, and what advice she has to share with nurses who are advancing their careers, at any stage of their career.

  • Why it is so important to increase your worth to make yourself more marketable, and how that worth is not necessarily linked to formal education.

  • Specific negotiation strategies, like anchoring, and avoiding negotiating against yourse.

  •  How nurses can secure their first job, those win a promotion, and negotiate with vendors and strategic partners.

Dayna Hennessy’s Info: 

LinkedIn: https://www.linkedin.com/in/dayna-hennessy-mba-msn-fnp-c-392434b5/
Company Website: Extend Fertility www.extendfertility.com

Transcript


Dayna Hennessy  00:00

Say what you want. Ask for what you want, say it with confidence. The worst they can do is say no.


Griffin Jones  00:12

increase your worth a lot of you fertility nurses and a lot of people in the workforce in general are being told to know your worth. I don't think enough people are saying increase your worth. And that's a message that I get from my guest today. Dayna Hennessy. She was a nurse, then she became a nurse practitioner, she went on to get her MBA. She's the Chief Operating Officer of Extend Fertility in Manhattan. And so we talk about how important is an MBA really, and Dayna has some opinions on how important it actually is, should you get an MBA if you're a nurse, or, or how necessary is an MBA to begin with? Are there other things you can do like increment your knowledge as opposed to taking that plunge? And then we dive deep into negotiation, not from what Dayna learned from her MBA because it didn't sound like she learned a lot about negotiation from her MBA, but rather what she has learned as director of clinical operations then CEO, going from nurse to NP to executive and we talk about increasing your worth, the difference between the positioning behind negotiation that gives you leverage, and then the presentation, the discussion, the fact finding, etc. So we talk about how fertility nurses increase their worth. We talk about the difference, parts of negotiation, discussion versus positioning, Dayna gives specific strategies like anchoring, like avoiding negotiating against yourself. Anchoring by the way is a lot easier when you have increased your worth having the people on the other side of the negotiation table, do some of the homework to help you. And we apply this to fertility nurses that are applying for their first job. We apply it to fertility nurses who are looking for a promotion looking to take on more of a business role. And we also apply it to fertility nurses who have taken on that business role. And now they're not negotiating with prospective employers so much anymore. They're negotiating with vendors and strategic partners. So in giving strategies for each of those situations, Dayna actually also gives us some examples real life situations where she has COO of extend fertility negotiated on behalf of the practice and times where it was successful, and then some examples where it was a lesson that she had to learn from. So I hope you enjoy this episode, the school of hard knocks episode for fertility nurses, with Dayna Hennessy, Ms. Hennessy Dayna , welcome to Inside Reproductive Health.


Dayna Hennessy  02:48

Hi, thank you for having me.


Griffin Jones  02:50

I am increasing the number of nurses that I interview this year at least I'm being intentional about doing that. Recently, we had Lisa Van Dolah, who was a nurse by trade and then went on to get her MBA, like you did, and then became the CEO of Ivy Fertility and it was a useful program for nurses who I think often don't get a lot of business education. Often I hear our guys reach out to me because they say they don't teach us business in medical school. Well, they definitely don't teach business in nursing school. So if doctors are at a dearth for business, education, then nurses all the more so so maybe we start with what was it that came first for you? Was it an interest in nursing or an interest in business?


Dayna Hennessy  03:33

For as long as I remember how I was going to be a nurse, since I was a little girl, and I stuck with it. And it was always nursing. Business School was never even a thought, in my mind, to be completely honest with you. It's my current role that put that thought in my mind. But nursing, I always knew I was going to move on to getting my master's in nursing to become a family nurse practitioner, which I did complete in the early 2016. But beyond that business school was never, never a thought. So


Griffin Jones  04:06

it was your role and that's Chief Operating Officer at Extend Fertility.


Dayna Hennessy  04:10

Yes, currently, I am the chief operating officer there. I started out as the director of clinical operations when the role was presented to me.


Griffin Jones  04:19

So you're in an operations role and I know you as a very operationally minded person, you function like a system and you're good with systems. So you could have pursued and MHA, you could have gone and and studied health administration for the upside at least I presume, why did you decide the MBA route over the MHA route?


Dayna Hennessy  04:42

So when I when I was finishing my practitioner, my masters to be to do practitioner, I was offered this opportunity with extend fertility almost simultaneously. And I was living in Florida at the time, but the opportunity came along To help build this new fertility practice from ground up with a physician that I had previously worked with at another fertility clinic that I thought I really admired and enjoyed working with. And when that opportunity came my way, it was something that you don't, you don't get those opportunities very often. So we jumped on it, we moved to New York pretty immediately. And I just think the role that was being developed, because again, this was a brand new practice, I felt like, I continued down the path of putting my foot in marketing, putting my foot in clinical operations, it wasn't just clinical ops. And when you, when you experience so many different facets of a business, you realize maybe business school will help me. Also I was surrounded by a bunch of people who had their business degree, and I kind of just felt like that was necessary for me. And then once I put my mind to it, I knew I was going to do it. And I graduated with my MBA at the end of 2021.


Griffin Jones  06:10

I want to talk about what you learned while you got your MB, but you said you were surrounded by people that had their business degrees, who were these people,


Dayna Hennessy  06:20

the Chief Marketing Officer, the CEO, you know, we, as the company grew, we brought in more people from the marketing department, many of which all had their business degree, our rent our CEO, original CEO, she was also a nurse, and she, she I admire her so much. She became an entrepreneur, and she just started, you know, becoming the CEO of many practices. And you when you're surrounded by you feel like that's the right the right path? 


Griffin Jones  06:54

Was it because you're just surrounded by them? And you're like, well, these people are successful and smart. Therefore, this is a precursor? Or was it because they were speaking a kind of language that you didn't totally understand, and you wanted to get some of that knowledge? How much of it of each of those was it?


Dayna Hennessy  07:11

I think it's, I think it's a little 5050, you know, to be honest with you, you're my drive and desire to, to grow as an individual, and, you know, make it at the top, I'll use those words, is very strong. And there's the component of feeling like, I need this to be able to get there. But at the same time, I didn't know anything about marketing or branding, or terms that were being used like leads and conversions. And you know, all of these different things CRMs, Salesforce, coming through and HubSpot, and all these different pieces of a business that I had never heard of or experienced in my nursing career. And so it was interesting and intriguing. And so I feel like it was a little bit of, yes, I want to know more about how to run a business, and then also feeling as if it would help me along the way.


Griffin Jones  08:16

So it sounds like some of the marketing terminology was the Greek for me, a lot of the Greek is the financial side, especially the investment, especially as we start to cover news on the startups that are raising, you know, $20 million here, and I need to go back into Investopedia. Look at Oh, what are you allowed to do in a series? A, I recently asked somebody, I said, Do you have to be an accredited investor to to raise money in a in a seed round? Like, I don't know the answer to a lot of these things. And so, so that's Greek to me, it sounds like the examples that you gave, were the marketing, were you stronger on the financial side? Or was that even more Greek,


Dayna Hennessy  08:53

I was even more Greek. When I first started with my position here at Extend Fertility, the financial part of it wasn't as much a part of my role. You know, I was hiring people. But the investments and the funding was not really in line with what I was doing, as I grew with the company that became more a part of my world. And so I think now it's even better that I got my MBA, but I didn't go originally because of the financial aspect of the business.


Griffin Jones  09:31

I'm putting myself in the shoes of a nurse that would be listening to this podcast and thinking, does he or she want to take the next step in business education, from what I'm hearing kind of sounds like you took a plunge? Was it a plunge? Like I'm wondering if someone's thinking, well, maybe I just take a master class in marketing online or maybe I take this one course about finance or I read the this series of books about financial reporting, or whatever it might be you It sounds like you, you had the exposure, you're like, Well, I've got this job and, and I'm doing the clinical operations, but I'm also being exposed to a lot more than just clinical ops and I see a pathway for more business ops. Was it a plunge for you? Did you consider more incremental steps?


Dayna Hennessy  10:18

Now? I was going all in?


Griffin Jones  10:22

Is that just the nature of you like? Yeah, you know, you and I know each other on a deep personal level, but I do get the impression that you are the type of person that's you're you're you're all in or you're not is, you know, I have the impression,


Dayna Hennessy  10:38

it might be a fault of mine. But when I put my mind towards something, I will do it. I will say, though, that I spoke about going back to get my MBA for probably a year, or a year plus, before I actually took the plunge. And I would speak to my chief marketing officer, and I would I would talk it out with him, you know, get his advice, see what he felt about it. I even went to our investors at one point, because I respect him and what he's done and said, What do you think about this? Do you think this is worth it? Do you think I should do this? So and I got mixed reviews, to be completely honest with you, I think nowadays, you can do a lot with experience, you don't necessarily need the three letters behind your name, to allow you to succeed. For me, it was just in my mind for so long that I said finally, I'm doing this, I want to experience it. And I did it. Whether or not I actually needed it to get to where I am now. I'm not sure. To be completely honest with you.


Griffin Jones  11:43

Well, let's examine let's let's put the whole concept of higher education under scrutiny, which I'm a big fan of, in general, putting the whole institution of higher education from undergrad to grad under intense scrutiny, maybe sometimes it's absolutely worth it. And but I would, I would blow my nose with my college degree. And we have an audience of people who they need their degrees, because they learned something very specific, they applied that specific knowledge to a trade. For the rest of us that have humanities degrees, we're on the other end of the spectrum. And then there's probably some areas in between. So what did you start to learn? And I don't mean, like, how was the material presented to you? I mean, what did you notice yourself starting to observe in terms of light bulbs going off as the material was being taught to you?


Dayna Hennessy  12:38

I think for me, I enjoyed the classes that I already knew some content, because when that was being taught to me, I was like, Oh, I know, I know about this, and I keep going back to the marketing piece. Because marketing, I knew nothing of marketing as a nurse you that's just not something that you're exposed to. And it was something that was very big to extend to us to extend fertility when we were first becoming a business. And it was amazing that I was a part of that. And so being in those classes, where I understood all the terms, and kind of seeing other ways to look at branding or ways to market yourself and first to market and second to market and the advantages and the disadvantages of these things. Was was interesting for me, and it was cool to to actually learn that and have also been exposed to it. You know, some classes light bulbs don't go off, because it's just not the way that you're going to use your MBA, you know, with all higher education, you take classes because they're required, whether you're going to go down that path or not. So capital, you know, financing was a class that I knew, you know what I'm going to get through this class, but this is definitely not my specialty and what I'm going to use my MBA for. So I tend to go to the side of classes that I was a little bit more familiar with. If that answers the question is 


Griffin Jones  14:19

Does any of those courses deal with negotiation did that come up in the course of your


Dayna Hennessy  14:25

negotiation was not a particular subject that I can recall, to be completely honest with you. It was mainly you know, how to become an entrepreneur, how to understand the finances of becoming an entrepreneur, how to market for that. We had two simulation classes, which were really fun where you get with you know, five other classmates and you basically open a business run it virtually, and we all had our titles, you know, there was the finance person, the marketing person, the CEO, that type of simulation And those were always really fun to understand supply and demand and what you need to do to be able to successfully run this business. They were never medical practices, which is very different also, by the way, then, you know, selling goods somewhere. But negotiation was not not a topic.


Griffin Jones  15:19

I want to talk about how you learned it through the school of hard knocks then but while putting higher education on blast, which they should be if negotiation doesn't appear, and MBA, want to ask of how, how much do you think it is? You alluded to a little bit of, well, are these letters necessary be beyond my name? Perhaps they are? Perhaps they aren't. I wonder how necessarily do you feel they are for an entrepreneur? I don't have an MBA, I own a business. I've done fairly well for myself. But I think a Bill Gates, Steve Jobs, I don't think I don't think Jeff Bezos has an MBA, I think many of those historic founders don't. And not just the historic founders, but the lady that owns a nursing recruitment company that she built from scratch. Does she own a does she have an MBA? Usually not does the guy on Long Island that owns a successful chain of H vac repair truck, like a fleet of H vac repair trucks? Does he have an MBA? Almost always not? And so how necessarily do you feel it is for being entrepreneur versus being the operator?


Dayna Hennessy  16:32

I think it depends on who, who you're trying to become a part of your business? I think with all things it, it's 5050 Some people care about it, and some people care nothing about it. It depends on who you're dealing with who you're talking to. Do I think it's necessary to open your own business. No, not at all. Do I think some people might respect the person more because they have those three letters, probably, even though they're not proving you know, that those three letters is why they got to where they they got, I'm a person, as a nurse, who I've always believed, I hated the term. And hate is a very strong word, but I'm going to use it when when you would try to get a job. And you're told I'm sorry, you're new, we need people with experience, because where are they going to get that experience? It has to start somewhere. So I am a firm, firm believer, especially at extreme fertility. If a new nurse comes my way, I almost always will give them the opportunity. Because I want to teach them and allow them to grow and learn. So same thing with this question of do you think it's necessary? I don't think it's necessary, per se, but I do think some people would care about it. And to, you know, invest, maybe, maybe the MBA is a criteria for investors to come along and say, You know what we think you know what you're doing. But trust me when I say I've worked alongside many people with MBAs, that didn't make it very far. And so three letters behind your name is not the only thing that gets you where you need to be in your career life, or otherwise.


Griffin Jones  18:19

The real is coming out, Dan, I love that. And it's because I just think that there's so many people that they watch Shark Tank, they watch Gary Vaynerchuk videos on YouTube, there's been a culture of entrepreneurship for the last decade. And it's put this emphasis on appearing like an entrepreneur, it's just execution, and it's so effing hard. And I am not discounting the knowledge that you could get an MBA because a lot of people listening to this episode, are putting their MBAs to good use. I'm just, I'm just writing it off as a categorical prescription like that everybody needs it all the time. And, and I did take a note of something you said about experience, starting without experience, because I want to talk about the operational systems that are necessary in order to be able to advance people that don't have experience. Let's, let's stay on the topic of negotiation. So if you didn't learn it as a course in your MBA, what have you learned about negotiation in your career? And at what points did you pick each lesson up?


Dayna Hennessy  19:30

I reflect on this question a bit, because negotiation in general is quite intimidating. And it's more so intimidating at different stages of your career. I believe you know when you're first but and we'll talk about since we're on nursing, fresh out of school, going to get that first job. Your negotiating power is probably not as high as someone who is a seasoned nurse with 10 years behind there with behind their back and that's just the way Reality. And so when you're a brand new nurse, you're kind of just excited to get the job at that point, and I think you don't, you don't learn much about negotiating quite. When you're fresh out of school, it's as you pick up the experience along the way. Now you know what you're worth, you know what you're walking into, and, and you know what you want. I think one thing that many people don't do is just ask for what they want, there's usually a beating around the bush or you undercut yourself, because you're worried you're not going to get the position, when in reality, you probably could have got what you wanted. So I, it's definitely a learning learning curve. And you become more confident as the experience is there, for sure.


Griffin Jones  20:48

So you alluded to two different things that I see in negotiation. One is the actual positioning behind the negotiation, that leverage that you have the number of opportunities that you have, and what you are really worth in a transaction or in a relationship, and then there is the presentation of it, the fact finding of it, where the discussion of it, where you're asking for what you want. And so in the beginning, what you're talking about a nurse coming out of nursing school, well, frankly, they're not worth a lot, in many cases, depending on what we're talking about, you know, it, but even that depends on who's on the other side of the table, right? Because if we're a nursing home in rural Montana, and we have to have a nurse, then all of a sudden, the person out of college is worth more,


Dayna Hennessy  21:43

I also really believe that it all comes down to particular circumstances, there's probably 100 Different examples we can give here, you know, let's let's just bring COVID to the table, you know, when COVID hit, they were desperate for anyone that they could get to help in hospitals. And I can guarantee it didn't matter what level of nursing you were, you, you had a lot of leverage there, you know, but also a different perspective, let's take a nurse who has been working in a facility or not even a nurse, it's you know, you're in school, you've you've chosen to work in a hospital or a private practice, maybe you know that this is the place you want to be when you finish nursing school, you are going to have a greater negotiating power, when you become a nurse versus the new nurse that these people know nothing about to get that position. And potentially, you know, the money you desire, because it's not just experience, it's also you've just proven to this management team, that you're reliable, that you are a great hard worker, and I can guarantee that they're going to take you over that new nurse, and now your negotiating power is a little bit different. So I think the question about negotiation is definitely a very big question. Because I think there are so many different avenues for where and why your leverage for negotiation becomes greater. You also can, you know, when you are somebody new in a company, what you know, hospital, nursing, whatever you can do, you can do other things to make yourself more valuable. You can go get certifications in other departments, you can learn how you know, as a nurse, I became a pic nurse. So I placed PICC lines, that is a total different avenue as a nurse that now I can put that out there that this is something else I can do a trade that not many people can do. And now I just made myself more valuable to be able to negotiate higher. So you kind of immerse yourself in all facets of the place in in the ways that you can. And now your negotiating power just keeps going up.


Griffin Jones  24:02

So I like the way you're laying this out in terms of increasing worth because we've established that there's at least two sides of the spectrum of the negotiation that there's the presentation, discussion, fact finding part of it, and then there's the actual positioning part of it. And you're talking about the positioning, part of it increasing worth, which I think tends to be under emphasized in today's Social Media LinkedIn world. You mentioned the employee crisis of 2021 and 2022, when there was an inflated worth, but I hear the advice No, you're worth often being given his bad advice. And it's not that it's bad advice just by itself. It's what it's really saying. Pretend you're worth a lot more than you are. Because eventually that comes to have consequences and you're talking about in Investing in oneself so that you actually have more bargaining worth to be able to work with. And so in the sense of those folks that they say, know your worth, well, when is it the time to say, No, I'm I am worth this, and I should be getting more. And when it is, when is the time to eat crow and actually build actually increase your worth?


Dayna Hennessy  25:30

I don't think anyone should try and say they're worth something more than what they actually are worth to be honest with you. I think, my


Griffin Jones  25:39

that's what they're being told Dayna. That's what we're all being told on social media. And it's, but but it doesn't say what we're actually it just says, You're worth more. I hear marketers being to charge more, like I hear employees being told, you know, ask for the raise. And it's in May, and there certainly times when those things are true. But it's like, that's the it's like, that's the standard default advice. And there's nothing behind it saying, here's how you actually measure, here's how you you weigh increasing your worth versus just trying to negotiate in the present.


Dayna Hennessy  26:15

So unfortunately, I think the the way society is is turning as far as the workforce goes is very different from when I came into the workforce. And I'm going to keep my values and principles of of what I grew up knowing. And I wish we were teaching more people that you know, right now, the yes, you're right, the employees believe that they deserve everything in anything, regardless of how hard they're working. And I don't agree with that. Because you are worth what, what you put out there, and how hard you work and the things that you do to prove that you're a hard worker. And there are plenty of places out there looking for hard workers. And it's actually harder than you think, to find hard workers. You know, I grew up my father owned many pizza restaurants and bars as as a child. So I grew up being around hard working individuals, and I would go and help my mom clean tables. And, you know, I just found it fun. And this was this is what I did, for as long as I can remember. And so my work ethic to always improve and do better, and make myself the best version of myself that I can be to show people that I was worth it. That's just a part of who I am. And I think I think everyone shouldn't be doing that. If you have a way to improve yourself in, you know, whether it's school, whether it's, you know, certification programs, whether it's just volunteering somewhere, do it that the social media stuff that you're saying, I'm not a fan? I'm not. I don't know how to say it.


Griffin Jones  28:08

I'm zooming in on this. And it because all of those things that you talked about increased your worth. And I very often see the social media debate focus on when they hear something like increase worth. They think it's like, oh, that's in the benefit of the employer. It's the benefit of the other party. No, in the long run, it isn't it is increasing your worth. And what I worry about when I see the things that we saw last summer, a lot is people would say, finally employees are starting to realize their worth. And then I've been on both sides of it. I was a commission only sales rep in the Great Recession in a poor city when I was 21 years old, and had zero leverage whatsoever. And the employers did treat them even the good players like garbage. I've been on both sides. I've also been an employer that's really trying their best to accommodate people and trying to compete with the market and trying to advance people, which is all really hard. So I've seen both sides. But when I see people say things like in a historically a typical time, like the summer of 20 to say they finally know what it's worth. It's like, are you really going to say that your house is worth what it is now in this ridiculous seller's market? Or do you really do want to bank on that? Sure. There might be times to take advantage of it in both the labor market and the housing market sell now get that job now get that promote? There might be times to take advantage of it on it. But do you really want to measure your worth on that? Because when it goes back down, then you haven't built the the actual staying power that that you talked about? Yeah, agree. And so it sounds to me like you've focused a lot on worth building part in a little bit less on the presentation discussion? factfinding part? How much of that have you gone on to focus on in later years, the actual way that you ask the questions you ask beforehand? Like, how much of that do you focus on nowadays,


Dayna Hennessy  30:17

I definitely grown in this past seven years in this role. You know, you start out, this isn't a new thing for me, I'm learning, there's always a humbling moment where you have to learn what you're doing and understand what you're doing. Before, there's some other forms of growth with being able to negotiate in different ways. I, you know, me a little bit Griffin, and I am pretty straightforward. Black and white, I just asked for what I want. I think that that's become much stronger for me over the years, you know, I am so used to having to reach out to pharmacy companies or certain vendors, and I'm actually dealing with one right now. And, you know, what, if they want your business, they're gonna probably work with you. And I learned through this business, that it very much so kind of works. That way, you don't always get what you want, don't get, don't get me wrong. But I just go out there. And I'm very confident, and I just say, look, here's what we need, here's what I want, you know, it's for the patient, or it's for whatever it might be for. And they're usually always willing to work with you. If you show any bit of lack of confidence, or, you know, I'm trying to think of another word here. But


Griffin Jones  31:48

what you're looking for is negotiating against yourself, which I see nurses do a lot. Yes, I think that's what you're looking for.


Dayna Hennessy  31:56

I mean, if you show them that you're kind of nervous to ask for what you want, they're going to take the upper hand, and they're going to be the one now in the power seat, to say, well, you know, whether you sense it or not, that's just what happens. And so when I just say, Look, this is what I want, they kind of know that there's no budging for me. And I gotta say, I've done very well, with my negotiating, I believe for our patients, essentially, for this, you know, within this practice.


Griffin Jones  32:31

Yeah. So you are talking about the strategy of anchoring, by the way. So there's different strategies in negotiation. One, sometimes people will say, don't anchor don't say what you want. First, don't say, Don't name a price, don't do any of that kind of thing. First, let the other person decide. And it seems to be more circumstantial than, then you could just say it should always be a or it should always be B. But in many cases, I think anchoring does work better. And I think that it especially works better, once you've established your own worth. And you're showing in this a willingness to walk away. So you're laying out what you want, are you Are you really willing to walk away from it if you don't get something? Or how much are you willing to come to the middle on things.


Dayna Hennessy  33:24

So I think it depends on what reference it's for, you know, obviously, if it's for a position or a job, and you can't lose your job, I think there's a lot of flexibility there, because you're in a position of needing to keep what you have in some way. But if it's vendors and things like that, I can promise you, there's more than one. And so, especially nowadays, people want your business in one way or another. So you don't have to just negotiate with one at any given time, you could have three negotiations going on at the same time. And I've used negotiations against one another to get the better deal. And you just learn these things as you go. And they work. So you know, there are circumstances where you can't back away and you meet in the middle. But generally speaking, there's usually always more than one opportunity.


Griffin Jones  34:19

Well, you use the example of being in three negotiations that you do have options you can walk away, and that is leverage. And the person with the most leverage is the one most willing to walk away. And, and so you talked about an example where you're negotiating with three different parties. Have you ever been on the other side of it, or at least perceived that you are on the other side of it? So you know, maybe you're one of multiple people negotiating with one for a deal or something that you really want? Can you think of an example like that?


Dayna Hennessy  34:55

I mean, I think the closest example would be you know, let's say a dinner nurse comes to us, and we're looking to hire and we really need this nurse. But she openly tells us that she's looking at other places at that moment, you know, okay, how badly do we want this person with us, and then you kind of are on the other side doing this, back and forth with them. And they have the upper hand, and that if we really need this person, and we we think she's, you know, she's great. And we want her to join. But we know that she's potentially going to go elsewhere. Now you're kind of at her mercy. So to think, what do


Griffin Jones  35:40

you do when you're negotiating with somebody that has the upper hand so that you say, okay, they've got the upper hand, I know this, I know what our need is, but you could suffer indefinitely, you could let it drag out? And definitely, so do you suffer indefinitely? Or do you do something when you know, the person has the upper hand is like, alright, you know, I know that I'm going to have to stretch here. But I'm also not going to let them just hold me Oh, over the fire, like a cat holding a mouse over the flames. Like for a prolonged period of time? What do you do when somebody has the upper hand?


Dayna Hennessy  36:17

Yeah, I don't, I don't think we've ever had, I would never allow somebody to dangle something over our head to make it be some indefinite indefinitely. Ron,


Griffin Jones  36:28

did you when you were younger, when you were fresh out of nursing school did because I let people do that, to me all the time. It was a commission on the salesperson I was 22 years old, I was walking into businesses selling a crappy product in radio advertising. And I learned some good habits of resilience and how to do everything and take accountability. I also learned some bad habits of, of just letting yourself stay in that low end of the totem pole for too long. And I definitely let people a hold me over. And it was like, you know, start just kind of coming of age thing meet starting to rebel against it a bit mid 20s and late 20s? And, you know, by the time you're in your late 30s, like, yeah, you built that worth that you were talking about building? So did you do it more in your, in your earlier career?


Dayna Hennessy  37:17

So I think there's two different sides to this question. If I'm the one in the seed of the new nurse reaching out to the employer, and the employer is, you know, kind of dangling me and not letting me know, as a new nurse, I'm very eager to get that position. And I'm going to follow up, and I'm going to follow up, you know, Send immediately after the interview, you send your email to them to thank them for the interview, which doesn't happen very often. So let me tell you, when it does happen, it's quite impressive. And whoever's listening can take that for what it's worth. But many people don't do that, because they expect that they're going to get the job, and you should never go into something expecting that you're going to get it you need to work for it and work hard for it. So I would reach out, and I would follow up to let them see that I'm interested in this position. And eventually, you know, you have your own inner timeline, if you're, if you really need a job, you you're, for me, I'm only going to sit on that for so long. And I'm going to be looking for other things. In the meantime, if I find something in the meantime, but I really wanted this first job, I will reach out to them and say, you know, I'm really interested in this position, I did find another place. So please let me know, in the next X amount of days, whether or not I'm gonna get this position, or else I'm gonna go over here. And I think that's completely fine for you to do. And that kind of gives that that reverses the upper hand a little bit back into your court to say, Look, you either want me or you don't want me. And some you kind of just have to be okay and comfortable doing that. Otherwise, you are going to just sit there forever, not not knowing what's going on. On the flip side as the employer, if I have an employee, not giving me a response, I can do the same thing. You know, hi, we would really like a response by the end of the week, because we are interviewing other candidates. And that kind of lights the fire for them to either you either want to be with us or you don't want to be with us. So it's it's kind of both ways.


Griffin Jones  39:26

In each instance, you're talking about going back and increasing your worth. So I love that when you're talking about I'm in a position where I want a job and I'm a younger nurse and they've got the leverage and they're kind of dangling me. You're still talking about increasing your worth. You're still talking about increasing your leverage. It almost solves for the challenge that you have it starts you said it starts to turn the tables the other way it starts to have a bit of a balancing effect. And that's a that's a good point. We got you've given re The good advice to nurses for that are entering the workforce and maybe going for the next job in their career. What about nurses that now find themselves in positions where they have to negotiate with outside? They've got to negotiate with vendors. And what was that process? Well, how did that start for you? What were the first things that you were doing? And let's talk about that for a bit.


Dayna Hennessy  40:26

If you're referring to when I first took this position as director of clinical ops, and at coming from a nursing background, now having to speak to outside people, luckily, I had fertility experience already kind of under my belt, before I took this position. And it's kind of a group thing, when you're such a small company, I think there were six or seven of us when we first started, extend fertility. And when people hear of you and know you're coming to market, you don't always have to immediately seek other vendors out, a lot of times they find you. And before you know it, you have emails coming in from these people who want to meet with you, because they see that you're about to enter the market. That's how it happened a little bit for us in certain parts of the company. In other ways, you know, you had to go get furniture, and you had to. I mean, it was it was very interesting building a business from the ground up. Not many people get that experience and I'm very thankful for it. We you just do your research. And you just it's it's cold calling these places saying hi, we need we need to set up a meeting and kind of review what services you have to offer and see if it's the right fit for us.


Griffin Jones  41:48

How much prep do you have to do for something where you've never negotiated before? So something like maybe meds or or other things? Maybe you have more experience? Because you had the fertility experience, but something maybe that you're doing for the first time office furniture, I have no idea what your the furniture in your lobby costs, like you could tell me it costs. He told me it costs two grand, you could tell me it cost 20 grand, I have no idea like so. So how much when it's something that's brand new to you? How much research do you need to do? And what research is it?


Dayna Hennessy  42:21

I don't think you have to do a ton of research. You know, depending on what market you're in, you take that information, there's going to be limited information on certain things. And you do a little bit of cost comparison, you know, let's use fertility medications. For an example. You have two main manufacturers for the main drugs. So when you know know that or don't know that going into it, you quickly learn it. Because there were people on our team that did not know fertility. And so there's not much research there, you find out what are they selling these medications for at all these different pharmacies, and then you go in seeing what you can get better. There's, you know, you do some research on additional programs or other things that can help patients along the way. And then you you do your best when you're negotiating those prices. But I think it depends on what practice you're in or what your business is on kind of how much research you need to do before negotiating stuff.


Griffin Jones  43:24

Well, it sounds like you're putting some of that research homework on the other party too, especially if it's something that you're putting out a request for proposal for you're putting out a quote for, let's just see, let's see what we can do for office furniture, you're contacting a couple of vendors, and you're putting some of that research on them, because they're bringing the ones and then you're comparing them. And so this for those of you on the other side, that this is where you can when you're in a lower level point of need. When you have less worth when you have less leverage, you can find yourself doing unpaid consulting. And sometimes it's worth doing that because sometimes that is what helps to increase your worth. But consider it in terms of increasing your worth over the long picture as opposed to something that you need to do in this particular case. And I think that was a mistake that I made all the time when I was young is that it was like it's either this deal, or this this job or this thing, or I'm a complete failure. And then I remember shifting gears, being in a business meeting with people that were way over my head and I was is maybe my late 20s or something and I was like, You know what, I'm probably going to look like an idiot here. I'm going to go into this meeting as best prepared as I can to not be an idiot. But the best way for me to not be an idiot is to do a bunch of these. And so, so when I stopped looking at, okay, it's got to be about this deals. Alright, you can get your butt kicked and embarrass yourself in this meeting. But you take a little piece of that to the next one. You're like, oh, that's what they were Look at that question. I didn't have an answer for that. And, and so it's about increasing your worth over time. So you talked about the the, the research that the other party can do for you, when you position when you're when you're in that form of position, what about how to things differ when it's like an ongoing relationship versus transactional. And I'm not an artist, and I've never worked for a pharmacy. But I know that there's a lot of commoditization to pharmacy, I also know that there's definitely some relationship where you want to make sure your patients are getting their meds that they're taking care of well, and so, and you're probably working with a pharmacy for a prolonged period of time versus office furniture, it's like, we're not going to need office furniture for another 10 year, and there's a million vendors and I can just beat him down to the to the best possible price. How does how does negotiation differ when it's singular transaction versus ongoing,


Dayna Hennessy  46:00

I think the original negotiation is always kind of singular, right? Because you're trying to get that deal and you're locking it in for furniture, actually, it's it's not, this is going to be the same deal one time, because inflation supply and demand, you're actually almost guaranteed to pay more now than we paid seven years ago, you're still looking for the best deal. But that's kind of just what it is, as far as the pharmacies go. Since we're using that as our example. The deal that we made with our pharmacy seven years ago still stands. Now there are certain aspects of it that you can't control. You know, if the marketing, the pharmaceutical company that supplies, the meds is going up a little bit in costs, they may have to go up a little bit in cost, and there's really not much you can do about it. But once the deal is in place, again, the it's not so much on me to do any negotiating with them. It's them trying to please us. So we get the, you know, monthly bi weekly, everybody's different outreaches how's everything going? Is everything okay? Do you have any concerns, because they want our business. And if they see businesses dropping a little bit, they're going to even more so reach out? What can we do for you? And you know, oftentimes, it's, they're doing fine. There's there's not usually issues or anything like that. But I think once you have that initial negotiation down, and you're now in business with these people, they want to make sure that you're happy.


Griffin Jones  47:42

How valuable is that those checkups, by the way? Like, are they actually valuable? Or is it just like, yeah, Hey, Dayna . Like,


Dayna Hennessy  47:51

I think it's like, Hey, Dayna . I mean, I love I love my reps, they all know me very well at this point. And they know how I operate. And so you know, I've gotten a lot of good feedback actually, with with my straightforwardness, because who wants to sit here and spend 45 minutes just talking about nothing, you know, I have tons and tons of new pharmacies coming through my email, weekly. And it's almost overwhelming at this point. It's like, once, once you're this far in, yes, you could have a conversation just to see if they happen to be, you know, they're able to do anything better. But I kind of know at this point, whether people can go better. And I know that I negotiated really, really well when we first started. So I'm happy with who we have. And you know, it's kind of being that whole first market second to market you guys are like 15 to market. And we don't need 700 pharmacies to do the same job. And especially when we have the reputation with let's say, the pharmacies that we have, we know that they're going to do the job, right. They've been doing it for seven years. They know how we operate, they've learned our ways. And now it's just a nice, simple relationship.


Griffin Jones  49:14

That's one benefit of anchoring in negotiation is the time savings that can happen in time and negotiation. Some times go against each other you can have time as an ally in negotiation time can be an enemy in negotiation. And there are times where it's like I don't want to find the best price for something I want it now and you you're willing to okay you're talking to a couple other people here's what I've got for you and then you see who gets the closest and and you move on quickly as opposed to seeing what where they're at and trying to tease that a little bit out and and so anchoring can absolutely save time and which is money and you're in a position to anchor better because you've Increase your work, you can anchor more when you have more work, it's a lot easier. And you know, the hottest movie star can say, I'm only going to do this role if I get $45 million in the international royalties. And I get to work with these co stars and this director, and There better not be one yellow F and Eminem in my trailer and a freak out versus the aspiring actor that's going to do voiceover commercials in order to be able to get there.


Dayna Hennessy  50:31

One thing that I noticed in that example, that I want to not necessary, clarify, but just comment on. It's interesting that sometimes there's an immediate increased worth with being an a hole a little bit is what you just described. And just to put it out there, that is not necessary. You know, and I know you're just using a funny example. But I want to make it clear that you can increase your worth and still be a very humbled person, because there's always something more to learn. And to be that person is just also not right.


Griffin Jones  51:13

So that's such, I'm glad that you brought that up. Because it's kind of tempting to sometimes drift into that person. Like maybe Mick Jagger was always the type of person to walk in and demand whatever you want. He could be, it could be that part of the reason why he rose to where he did is because he's that type of person, and that that cult of personality. But then there also is just as you as you start to get more than as you start to expect things a certain way, I think there's a bit of a temptation to drift into that. And if I'm being honest, I have to be cognizant of it. Because I'm a person that is a dog on a bone for whatever the bone is. And I need to remember that people in the way are not, they're not like obstacles in life. They're not things to be climbed over. There's polite ways of saying I'm so sorry, I can't talk to you right now. I'm so like, I wish I could or maybe we can set up 15 minutes later, or, because when I'm in dog on the bone mode, it's not that I was ever trained. I was I was taught that I could be in a hole or that I think it's okay. And I don't think I've ever ever been close to the worst offender. But I have noticed things where it's like, No, dude, six years ago, you if you saw yourself as a stranger, that would not have been acceptable. And I start to start to notice that. So are you willing to admit to ever having drifted into that? Or do you feel like you're really conscious of it?


Dayna Hennessy  52:43

In my position here, I'd like to think that I'm very conscious of it. I, I know that I for sure drift there in certain situations where somebody's just not, you know, let's say at some random vendor, I shift there when I get an email from a person who believes that they can help us fix the world. They can't even say our company name right. You know, instead of extend fertility, they're saying extended fertility, which is one of my biggest pet peeves. And they spell my name wrong, you know, in the title, and then they're like, let's have a discussion, I can help you with everything. And I drift into that meet like that, that kind of mean zone when I'm like, okay, buddy, you know, you didn't get anything right email. So


Griffin Jones  53:35

it was copied and pasted. And it may have even been copied and pasted by a robot too.


Dayna Hennessy  53:40

But that shows me that you don't actually care about our company, and I'm not wasting my time on you.


Griffin Jones  53:45

I think I think that's where it is. In other instances,


Dayna Hennessy  53:49

I like to think that I'm very conscious of that. Because I think things go a long way when you're in leadership and management, to be able to get what you desire or wants by being firm and confident, whether it's a vendor or something internally, but also being humbled enough to know that there's always you're not always right, or there's always something new to learn. And you're you're a mentor to many of the people that are watching you and look up to you, and you want to be there to support them. So I think it can go both ways. But that's what I that's how I would respond to that.


Griffin Jones  54:32

Are there any mistakes that you made when negotiating with fertility vendors? That one you can think of off the top of your head? And two, you're willing to admit to actually, you know what, I


Dayna Hennessy  54:43

will say one, and this is a big one so well to I have to whether I should say them or not, I don't know. But I will. I'll name this one. So when we first started, we thought Salesforce would be a great CRM for our company. Salesforce isn't, is an amazing platform, I have nothing bad to say about Salesforce itself. But it is a monster of a CRM platform for marketing. And I think they promised a lot of things that that Salesforce could do, that we thought would be valuable to extend fertility when we were first becoming a practice. And it took a little bit of time, I mean, we did use it for a year and a half, we built custom scheduling systems in it, we spent, you know, a good amount of money to build the systems and make it work for us. But then you kind of get to a point where you realize this is not actually working. And you have to kind of cut ties, and you're like, you know, that kind of sucks. The a lot of time and effort went into it. But it's not ultimately going to be a good thing for us long term. So you just have to end and ties with it. You know, there's other examples like your fertility, EMR, you have to pick one, and not all EMRs are good EMRs. But once you're kind of elbows deep in the EMR, it's never easy to make a full change, even though you really want to because, you know, there's better out there. But that that's two quick examples.


Griffin Jones  56:21

So the lessons they're being watched, be willing to walk away from sunk costs. Sounds like the first one. And the second one is, when it's not actually sunk cost, it's your it's you really are in a position where mobility isn't that much of an option, there's a greater cost to potentially switching. The second lesson sounds like it's live with your decision.


Dayna Hennessy  56:45

Yeah, or or you, you make the change, which I think will happen very soon, eventually, because it's been my mission for seven years. So when I get my mind to something, like I said, I will, I will make it happen. That is, that is my thing.


Griffin Jones  57:02

It was one night and seven years in the making that that it happened so well, you've given us a ton, I would rather I would recommend to the vast majority of nurses to instead of taking a business class on negotiation with 75% of the business professors in this country, I would go if you can shadow Dayna , for see if they need to travel nurse, do they need to travel nurse and just go to Manhattan for a month and see if you can be under Dayna’s tutelage. And you've given us a lot to think about the difference between the presentation and discussion and negotiation versus the positioning behind it, increasing one's worth, and particularly how to do that as a nurse, not just know your worth, but how to actually increase your nerve. Anchoring, avoiding negotiating against yourself, having the people on the other side of the negotiation table, do some of the homework, ignoring sunk cost, and then either living with the decision or making living with the decision if you can't correct it, or correcting it, if you can. So you've given us a ton. What would you like to conclude with?


Dayna Hennessy  58:13

Oh, man, I would in spirits of the topic, I think I would definitely recommend for new nurses to try or pre nursing, I keep saying new nurses, but try to seek employment in the place that you want to be, so that you have the most negotiating power to get the position. Once you finish nursing school there. Say what you want. Ask for what you want, say it with confidence, the worst they can do is say no. But at the end of the day, you will likely be in a negotiating spot at that point. And always do research on the company. You can find out through platforms Glassdoor. Indeed, what starting salaries might be so you have a starting point. You know, don't even if it's not even within your range, don't go there and maybe find something different. That's what I would say as far as negotiating power. As far as the NBA situation goes, I, I don't want to discourage people to get their MBA, if it's something that you've had your mind put on and you're like me, and you're just going to accomplish what you put your mind out to do. Do it, you're gonna learn some valuable things. But I think it's very situational on what, what you want to do. Ultimately, with your career. If you're a clinical person, an MBA is not for you. Go go into different clinical certificates. But if you're looking to run a medical practice, maybe it's something more worth looking into. I don't think it's entirely necessary.


Griffin Jones  1:00:03

Well, I've enjoyed learning from the school of hard knocks with you today and I imagine that our audience has as well. And if you are going to email or LinkedIn connect with Dayna after this episode, it's Dayna with a Y, Ms. Dayna Hennessy. Thank you very much for coming on inside reproductive health.


Dayna Hennessy  1:00:22

Thank you so much for having me, Griffin.


Sponsor  1:00:25

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

180 Quality Of Fertility Operations vs. Financial Efficiency: Solving For The Trade-Offs, With CARE Fertility’s CEO, Dave Burford

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


This week, CARE CEO, David Burford, joins Griffin to discuss what goes into the operational and financial decision-making process behind CARE Fertility’s business model.


Listen to hear:

  • The tension between financial and operational divisions of a fertility center.

  • Examples that look good (or bad) in a financial model, but then have good (or bad) consequences in operations.

  • Certain elements of operations that served the clinic, but not the patient.

  • When staff needs are at odds with patient needs, and the trade-offs that need to be solved for. 

  • CARE’s HR machine and the concept of necessary, if not immediately efficient, redundancy.

  • The mass retirement of physician CEOs, and what that means for the fertility field as they are replaced by business people without medical degrees



Care Fertility Group Limited: https://www.carefertility.com/





Transcript

David Burford  00:00

First and foremost, finance is very good on spreadsheets operations is very bad on PowerPoints and spreadsheets operations is about people. And it's about process and you only really can deal with one when you understand the other.



Sponsor  00:14

This episode was brought to you by Univfy. Download Univf;y’s free IVF conversion and revenue calculator at univfy.com/IVFpatientretention. 

Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests' appearance is not an endorsement of the advertiser.


Griffin Jones  00:54

Redundancy, is it time to start laying off some of your fertility center staff or is it time to hire more because you need duplication in order to positively impact their performance management? This is just one of the topics that I cover with my guest Dave Burford today Dave Burford is the CEO of CARE Fertility. That might sound familiar to you because we recently had their chief scientific officer Allison Campbell on the show to talk about embryologists owning equity and fertility clinics taking equity in startups, you should listen to that episode if either of those two topics interest you. And you may have read an inside reproductive health article a couple of months ago about how care fertility recently made an acquisition in the United States in North Carolina because with their financing from Nordic capital, they're expanding beyond the UK and Ireland into Europe into the United States and possibly other parts of the world. Dave and I talked about the convergence and divergence of the financial and operations divisions of fertility center. I press him for examples of when something can look good or bad in a financial model, but then have good or bad consequences in operations. When Dave took over as CEO of care some years back, he said that there were examples of operations that serve the clinic but not the patients. And I asked him for specific examples in patient intake and in call center reception and scheduling. And then I pressed Dave a bit because there are examples where staff needs are at odds with patient needs. And the trade off has to be solved for I asked Dave to describe CARE Fertility’s Human Resources machine because with 1200 employees, I asked him to talk about the balance between efficiency and profitability and on the other side overlap and duplication so that you can support your team and support performance management support the advancement of employees, I asked because this is something I've really been working on as a business owner very deeply for the last six months. And it's funny to have someone from the United Kingdom on because layoffs in the UK are called redundancy, someone who is laid off is redundant. And I observe this tension where you might want to have efficiency and profitability and only have a certain staffing ratio. But if you lose someone that puts a tremendous stress on the staff, it makes it harder to hold people accountable because they end up having to do other people's work. So it's a lot harder to hold them accountable for their original outcomes, it's harder to advance them, it's easier to burn them out. It's harder to get rid of a cancer when a cancer comes into the organization. And worse the cancer has bone dry tinder to set ablaze because the rest of the workforce is burnt out and not supported and doesn't feel like they have the autonomy and doesn't feel like they're able to grow in their careers. So we spend some time on that topic. And then Dave gives examples where he has to pitch to the board or pitch to investors reasons for making certain investments that will be good in the mid and long term but don't necessarily look great. In the next quarter. I asked him what data he uses to make those arguments. I then asked him to talk about the balance of when you start something new and you test the concept versus how much needs to be invested in and built ahead of time so that the deliverable is positive. I asked Dave, now that we're starting to see the original CEOs of many fertility groups, who in many cases were physicians start to retire and they're being replaced by CEOs who were not the founders of those clinic companies and who very often are not physicians, they come with a business background, how temporary or not should these new CEOs be? Should they be around for a really long time? Should we expect to see a revolving door of them? Are they going to be a symptom of cutting fertility clinics to the bone and selling them at a higher profit and that churn just repeats? Finally, we part with Dave's thoughts on what he perceives to be the cons of a more process driven sale in the United States than in the UK in Europe. I asked him if he feels that it is more process driven in the UK and Europe. Why that is the case in his view, and if it is true, what makes it a bad thing? Please enjoy this episode with Dave Burford. Mr. Burford Dave, welcome Inside reproductive health. Oh, hi,




05:02

thanks for having me.




Griffin Jones  05:03

You're now the second leader of the care fertility leadership team that I've had on the show recently, your colleague, Dr. Campbell had joined me. And that was a very popular episode because we did a little more content for the lab folks than we usually do. And they were very interested in her talking about the career path for embryologist. There's a whole lot of places we could begin our conversation today with you being a CEO of such a large group, but one that I'm thinking of is probably germane to many people that are at a point where the founding physicians, the founding CEOs, or the earlier CEOs are starting to retire, and now CEOs from the next generation that are taking over. And that seems to have been your case, it seems that you worked for care at a higher level for many years, and then became the CEO in 2018. Is that right?




06:04

That's right. Prior to that, I was the CFO. And then I moved into the CEO role. For a short period of time, I did both the operations director role and the finance director role, and then moved into being the CEO in 2018. So I've had a kind of broad view of fertility and wearing a few different hats, but obviously a very different experience than somebody that has been a clinician or an embryologist.




Griffin Jones  06:30

Sure, that broad view I want to talk about if is how much of an advantage that is in taking over an organization at the top being able to see it from different vantage points. But to make sure that I've got my history that was Professor Fishel. That was he the the original CEO.




06:50

That's right. Yeah, he founded the business and was the CEO for all since 1996. right the way up to sort of 2015. And then there was a short period of another chap that was the CEO, and then me from 2018.




Griffin Jones  07:04

Okay, so you're the the third CEO total in the company's history. That's right. And so did you know that you are gone? Was this a track that you are interested in from the beginning looks like you started with the company in 2014. Was that in the finance role?




07:22

That's right. So prior to this role, I was at KPMG. So I'm an accountant by background and was looking to get a real job if you like outside of outside of accounting and moved into care, fertility not knowing a whole lot about IVF. But knowing that care was a respected good business in the Nottingham area, and it was a it was a job that I was very happy to get. And then really progressed through finance into operations, mirroring the challenges of the business, I think so the financial challenges of an IVF clinic, or a small group as it was then, uh, not that big. But the operational challenges were quite significant. And so my role morphed into operations, which then set me up quite nicely for being the CEO when, when that role became available.




Griffin Jones  08:13

Had you thought about that? It from the very beginning, did you know that you wanted to be on a track for CEO leadership, whether it be a carer or some other company?




08:25

I mean, that was ambitious insofar as I wanted to go as far as my career would take me, but I wouldn't say I set out to be the CEO, I set out to really understand business, my passion is really understanding what makes a business tick. How can you improve it? How can you take it forward, and that tends to be operational improvements. And so it became clear that my finance role would only take me so far. And if I really wanted to change the way that the business was performing, I needed to move more into operations. And that naturally led on to being CEO because you get a really good grounding, particularly if the businesses, private equity backed, you get a really good brand grounding in both the finances and in the operations. And really, that's the meeting there have a kind of corporate CEO if you like,



Griffin Jones  09:17

it sounds like it was a smooth transition from finance to operations. But in my view, it seems like more of a jump. So was it what kind of transition was it how did you go from a financial role to an operations role?



09:32

Where the it was really mirroring the challenges that the business was facing at the time we've we've always been a really successful so we've been going for 25 years and we've always been a very successful clinical business. So very strong success rates really good clinical innovation, as I'm sure you heard from Allison when she was with you, but the challenges of the business were that the founders were extremely good doctors and embryologist and good business people. But the challenges of running a multi site operation are, are different to that of running an individual clinic. And we had increased competition in the UK, and some of our operational processes needed improvement. And rather than just being a finance director that was happy to throw a few stone, shall I say, my, my director, colleagues saying, you know, why don't you do this? Why don't you do that I was very happy to roll my sleeves up and, and get involved. And I really enjoyed that side of the road, the ops director that we had at the time was looking to move on. And so it became a natural progression. And I did both roles for a short period of time, the CFO and the CFO role. And then that became unsustainable, and we recruited in replacements for me really to allow me to move on to the CEO role, but it was really reflecting the challenges of the business and my passions really for operational improvement.



Griffin Jones  10:57

Well, your passion maybe came from wanting to throw stones, but them saying back to Yeah, well, if you think it's so easy, buddy, why don't you come over here and try it? And he said, Okay, maybe I will



11:09

use funny you should say that, because we actually had a board meeting where the private equity investor at the time, was not very happy with some of the operational performance in London, and said exactly that way. You've just said to me, Well, if you can do better than Dave, why don't you do that? And so I said, Okay, I'll do a I'll do a month secondment to London to improve London's performance. And that really was the audition for being the ops director or the CIO, as it was at the time. So yeah, that was exactly what happened.



Griffin Jones  11:41

Well, there's a lot to dig into here. Because one of the biggest criticisms about so much external finance entering this field of medicine is that there is a financial pressure and sometimes an oversight on operational quality, there's operational improvements to be made. For days in this field, there's, there's no shortage of those. But there is also the reality that there is a way of looking at things where it can be just looked at from a spreadsheet without the consideration of actually making the operational improvements. And you had to at least experience some of the other side. So what were a few of the surprises that a way to do.


12:28

I think first and foremost, finance is very good on spreadsheets operations is very bad on PowerPoints and spreadsheets operations is about people. And it's about process, and you only really can deal with one when you understand the other. And so if I take this back to care's challenges, at the time, it was very much around a business that was geared up to serve the clinic rather than the patients. And that's okay, when you've got a lot of demand and not much supply. But when when that dynamic changes slightly, and you've got more competition in town, then you've got other people that are doing things in a more dynamic way. And actually, the challenge is bringing in supply or patients, then you've got to change your processes to adapt to that. And you've got to be more patient friendly. And you've got to be more adaptive and fluid in the way that you deal with things. And so the he only really do that by talking to the people on the ground, talking to the staff and understanding what their challenges are, and then adapting the processes to meet the demands of patients and the needs of staff. So it was for me, it was nice to get away from the laptop and then the PC, and to actually talk to people and understand what is it that is the challenge here. And that's best supported by a bit of data, if I'm honest as well, because sometimes anecdotal conversations only take you so far. And you need to have a bit of skepticism about what you hear. And then you need to look at the data and say, well, actually, look, we've got 1000 people call in is it that seven o'clock at night? You're telling me that patients don't have a demand for late night calls. But why have I got 1000? Why have we got 1000 people ringing me when when the lines are closed, and it's just tweaking that some of those operational processes to meet those needs? Generally not that challenging, but involved. You


Griffin Jones  14:25

mentioned that at the time, there were some things that were serving the clinic but not the patients. What were examples of that.


14:34

So you know, people set up processes often to meet the needs of either themselves or at the time the needs of patients or customers but things change and it takes sometimes longer for processes to change. So a good example of that where it's really important for doctors in this field to understand the medical history of patients so that they can give the patient the most informed consultation that they can give them so that the patient is getting best value for money. But there's a line there commercial or operational line, if you like that judgment between getting as much information as you can to make the consultation effective, but not putting patients off from coming to see you because you've made that process so difficult or more challenging. And so we really went through a process of thinking about where's the balance here? How do we get the information that we need to make sure that consultations and appointments are as effective as they should be, but not overwhelming the patient with requests for information that either put them off? Or made them think about going elsewhere? Because if you ring up two clinics, and one Clinic says, Yeah, you can come in tomorrow, don't worry about it, we'll see. And the other Clinic says, Well, can you fill in this 60 page questionnaire before you come in? There's a lot of people that will just choose to go to the clinic, with no information just simply because it's easier and quicker. And particularly when you put that in the context of most IVF patients between the ages of 25 and 45. And so that those people have grown up in a generation of technology and ease of access, not filling in lots of forms and ticking lots of boxes. So it's about mirroring that, that really and changing those in those demands. And that's a practical example of some of the things that we've done as an organization to make that access to patients, informative to our staff so that it's meaningful and productive, but slick and easy from a patient's perspective so that we can attract as many of them as possible.


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Griffin Jones  18:11

I want to talk about how those two things reconcile staff's needs and patients needs. You also mentioned that you were talking to staff and finding out what their challenges were, what did they tell you? Their challenges were?



18:25

Most of the time its challenges with the systems. And we've we've got our own in house system that we've spent 25 years developing, but in IVF, as I'm sure you know, there is lots and lots of different systems out there. But none of them are amazing,



Griffin Jones  18:39

referring to electronic medical records, correct?



18:43

Correct. Yeah. And so, you know, clinical staff want to do what they love doing, which is treating people clinically and talking to patients, and they don't want to spend hours in front of a computer and ticking boxes and moving pieces of paper around. And so it was really listening to them in terms of how can we make the system as slick and effective as possible, to make their lives easier. So that's how we fulfilled the needs of the staff. And there wasn't really much of a conflict between the needs of the staff and and the demands of the patient. The there was the only thing I would say where there's a small conflict is staff would typically want to have as much information as absolutely possible about the patient in advance. And we wanted, as I said, Put to put a bit of balance to that. But that's nothing more than you know, just communicating with staff, explaining to them the reasons for why we're making some of these changes, and then them seeing the benefits of those changes.



Griffin Jones  19:43

And so what about times where there are there is a bit of a conflict and I couldn't think of an example if the patients who want evening hours for reasons that you mentioned, they're in the demographic that they're in the demographics of their working prime and they would love to, in many cases to have a 7pm consultation. And then you have a call center team that says, yeah, right, Dave, I can barely get enough employees right now to staff, my current team. And they're telling me they want more time off. And they're already asking me for a raise. And I'm at risk of losing these other two. And we've had this opening for eight weeks. And so how do you reconcile those two?



20:25

I mean, one of the advantage of being a large group is that you can have more sophisticated processes in place. And I guess one of the things we're used to in the UK, and it will take us a little bit of time to establish this in the US is, we have centralized teams to do this and virtual teams, so they can work anywhere, and have calls with patients from anywhere. And so you then fishing in a much wider pool of employees to be able to satisfy that need. And actually, for some staff working, what were for some people we considered unsociable hours is perfectly fine. That's what they want to do. They want to work those hours. And so enable it, as long as you've got the right mix of people, you can do that. I mean, to be clear, out of ours, we tend to focus on just making sure that patients can contact us rather than having full blown clinical consultations, because that would be more challenging. But we we provide services to them out of ours, just in terms of contacting and talking to us, which often is enough.



Griffin Jones  21:27

So you need a well oiled Human Resources machine in order to be able to accomplish that though, don't you?



21:33

That's right. Yeah. If you ever



Griffin Jones  21:35

read the book, traction by Gino Wickman, or heard of the Entrepreneurial Operating System, you've probably seen some version of different accountability charts. But their version of the accountability chart is that you have the CEO on top and CEO is what they who they would typically refer to as visionary integrator, and then having three core functions of the business that they would call operations, which in our case, you might have lab operations, clinical operations, you have sales and marketing. And then you have finance. And they often lump legal in with Finance, any thing that has to do with compliance, they put with the finance side of the accountability chart, and they put human resources over there. And I'm not convinced that it goes over there. I don't know if it goes in operations, I don't know if it belongs is it's for thing and its operations, sales and marketing, finance, and then human resources. How do you think that it relates into an operational system,



22:34

specifically for human resources, I would argue that there's a sort of foundational layer that sits across those pieces, because you've you've got to get the culture of the business, right, you've got to get the, the quality of the staff in right in all of those three functional support layers. And so HR needs to sit across that I mean, from a technical reporting point of view, Human Resources report in to me directly. So I work with the group, human resources director to and literally tomorrow, I've got a three hour session with her around succession planning, and the quality of the senior management team making sure that we're developing the senior management team. So I think, you know, people like business such as healthcare, Human Resources can't be a module of finance, if you like, that's down there with reporting, that it needs to be high on the agenda, with, in my opinion, direct access to me as CEO, because we employ 1000 people. And we need and our business is very much around people interactions with patients, whether that be virtual or face to face, it's all about interactions with patients. And so the staff, the quality of our staff is critical. So I would see it as being a foundational layer really sitting across those those functions. I would also argue, by the way that in a business, such as as that sales and marketing, plays second fiddle to customer services, and you've really got to have a really high performing. We bucket that all together sales, marketing, consumer services, all as one big department because there's no good having a really hot marketing department and then having terrible customer service because a lot of our business comes from reputation, word of mouth, repeat business, and that is much more effective than spending millions of dollars on marketing Pay Per Click adverts. It's so having that one view of the consumer journey the consumer lifecycle is really important.



Griffin Jones  24:48

The customer service piece of sales and marketing is that which latches sales and marketing on to operations and makes it fluid and the sales and marketing Beyond that overlap piece should really be the activation of that piece. That is the activation of that experience that they're able to achieve. On the on the HR side, you have to have a system for advancement, you got to have a system for retention, you have to have a system for recruitment. Otherwise, things can buckle, and then you can start to have a lot of challenges delivering to the patients and then you can really start to have conflict between what the patient's seen what the the employees need. Did you find that balance harder? In late let's let's call it mid 2021 or early 2021? Perhaps to let's call it mid to late 2022, than any other time in your career? Or is that just me?



25:54

I think we've posed COVID, we've all had significant challenges, right. And I think we as a business have gone from predominantly work in the clinic, culture, head office function based in one city, everybody turning up to work to other than the clinical staff, obviously, having a lot of people working from home, a lot of people, and we're seeing now, some of that coming back, we literally had a conversation with a staff member this morning about feeling disconnected from the business, and feeling quite upset about that. So we have a big meeting on Monday with the senior team were one of the topic, one of the topics is how do we keep the efficiency of the working from home model because it's undoubtedly more efficient, but made sure we don't lose our identity and people's connection to care. Because we believe ourselves to be, you know, the care family. And it's really difficult to maintain that when people are working from home as much as they are. So I think we staff retention culture, it is more difficult now, undoubtedly, because of some of the dynamics that have been created in the post pandemic employment



Griffin Jones  27:06

market. So you might be the perfect person to ask having an operations background and a finance background. And being from the United Kingdom, where they use the word redundancy in the labor force. Because one thing that I had been considering a lot as, because I really struggled with meeting client needs without driving my team crazy in late 2021 and 2022, when it was so hard to recruit, and I've been completely, I've since completely revamped my human resources system and, and now really have a system and I tell people that I'm, I think that I'm a yellow belt at it right now. And then when I write a black belt, I will write a best when I when I am a black belt at it, I will write it in New York Times bestseller, you'll see it in the Heathrow Airport, you'll pick it up off the news rack and whatever the digital version of that in the meta verse is, and I really believe that I will be able to knock it out of the park. But right now I'm a yellow belt. And one of the the or two of the opposing forces that I'm really trying to master that with efficiency, and that with redundancy. And I'll lay the premise that I believe that recruitment is a retention strategy as well, for two reasons. The first is, it's really hard to hold people accountable to their seat, if you're asking them to do more and more things outside of their seat without that which they need in order to be able to accomplish it, you have to have more people coming in, or at least a replacement level to come in so that you can maintain that level of accountability. And second is that if you get people in that are not fit with the culture, or they are not able to achieve their outcomes, and you're not able to replace them that that can turn into a cancerous environment real fast, and they can barely and why not take a vote of no confidence? Because if the other if the great people are feeling stressed out and and not getting the resources they need, then they then see. Yeah, so that premise is that retention it recruitment is a necessary strategy for retention. And I see redundancy as being somewhat necessary in order to make sure that we constantly have people coming in so that that people can be accountable for their seats, they can be supported, and that we don't have the stress of it being several months of people having to bear a burden that they shouldn't have and then all of the cultural issues that come from that. And then I've been thinking about this also a lot because we say layoffs in the United States but when people are let go in the UK it's often let go to redundancy is that so? You coming from finance Were in a perfect world, we don't want any of that redundancy versus operations were having to you have to consider the needs. What's redundancies place? And all of that?



30:12

I'm picking that question, I would say there's two elements to it. One is performance management. And one is redundancy. And I think the lack of performance management is really corrosive in an organization. And, and, and that's holding people to account for their performance. And if you don't do that, and if you allow poor performance to prevail, then it's really corrosive to good performance. And it's really demotivating to those people that are doing a good job, when they see people doing a bad job, not being held to account. It really is a it's a very corrosive part of the business, and it can be very demotivating. And so I think performance management is critical in any business, and particularly in a in a people led business, such as ourselves and a decentralized business as well. So having having really good performance management systems and processes in place is critical when you're running multiple sites, because you can't manage that from the center, you have to delegate that down to the managers, and you have to provide them with good tools, good systems, and good training to be able to know how to do performance management. So we, we follow the kind of bell curve of performance management and that we would anticipate that in any given clinic, any given department, you should have some people that are poor performance, and people that are exceptional, and the majority of people in the middle, and really try and educate our staff on how to use those tools. So I would say performance management is is a main part of what you're discussing. I think redundancy comes in different layoffs come in different different packages. So we have very rarely resorted to redundancy. And even during COVID, we didn't really do much of it. But it is from time to time, unfortunately necessary. And I would say it's necessary, really in two main ways. One is the roles just change. So you know, the world moves on and you no longer need people in a certain role. And that role becomes redundant. And it needs to progress because you now need people that are doing chatbots, rather than answering phone calls, you know, that kind of evolution of the business. And if you don't evolve with that, then you might be doing somebody a favor in a very short term, but the business will suffer in that in the medium to long term. And so you've got to do what's right by the business, which ultimately is right by the staff, as well. And the only other period of redundancy that should be considered is in a downturn of trading. But you know, Touchwood, IVF is a pretty resilient sector to be in. And there's not that much need for redundancies as a result of downturns and trading, but never say never.



Griffin Jones  33:04

How about redundancy in the form of overlapping roles, or perhaps additional roles that you might not exactly need that person. But I've coming to see that as a necessity for performance management. So one of the ways that we have been onboarding our new folks, and even with the the team that's been here for a little bit, we've created an outcome hub so that each person has their own outcome hub. And so there's outcome hub for your seat. Okay, David, here's the three to seven main things that you're responsible for. And then we have rocks that which are like quarterly priorities or priorities that take several weeks to accomplish. And each of them are associated with one of those seat outcomes. And so when you start, we go over them in detail. I'm as explicit as I can be on what the outcomes are. And, and then I delineate what we have, and what we don't have for you to be able to achieve the outcomes. And we do that from the very beginning. And so it's okay, David, your your job is to grow the LinkedIn audience by 10%. By the end of second quarter. Here's what I have for you. We have these former campaigns, I have this designer on your team. Here's what I don't have for you, I don't have a, b and c. And then we agree. And so what I've found is that I need to have those things in place, which are very often people that can be moved from one scene to another if need be, or if one of those things, if we lose one of those people that we can replace them very quickly, so that I can hold my people accountable. And the further I get into this, the more I see the two as intertwined. So if redundancy is something that often means layoffs, what's the necessity of an overlay? app that might not make financial sense on the immediate line and in the spreadsheet. But that is absolutely necessary for keeping the operational machine going.



35:12

I think overlap in the way that you describe it comes into two ways. To me, I think you've got succession planning. And when you've got some really great people at one level, and you can see a role for them in a higher level, where they can add more impact into the organization, if you, you've got to go with that. And you can't be selfish insofar as or cautious insofar as well, they're doing a great job, let's leave them there and bring somebody in above because it demotivates them, and also the person you bring in above might not be as good as they would have been. And so there's a real need, when you get that situation, when you see these rising stars, when you see these amazed at this amazing talent, that you've really got to let them shine. And the only way you can really do that is to have a bit of overlap and bring in some resource at the lower level, to work alongside them to then enable them to elevate up into the, into the higher position. So I would say there's definitely a need for overlap is I see it in that situation. And, and the prize, then is that you've got talent from within growing up in the organization. And that's one of the things that we've very proud of. And we've done in many, many situations, our current director of integration was our previous IT manager who's been with us for 25 years, and we've moved him into a new role. But to enable that to happen, we we brought two people in to succeed him in his it role, we had a bit of overlap, they hit the bottom of the line for the p&l for a while. But we're now reaping the rewards because our integration director is got such a wide variety of experiences. That one, he helps us with integrations, he can help with all sorts of challenges. And he's a great guy as well. And we've invested in him. And he's he's moving on. So I think you in business generally. But specifically, in your point here, you've got to take a midterm view on these things. And the way to convince investors to take that view is to demonstrate to them that you're making the short term quick wins, you're taking them. And you allow them to use some of those short term quick wins to invest in the medium to long term growth plans, because they want them to but they'd soon lose interest if that's all you were talking to them about. And you'd be ignoring the current p&l, let's worry about tomorrow, they would not like that. But if you can demonstrate to them some good performance, some quick wins, you buy your freedom to invest in the medium to long term, and overlap, as you call it, or succession planning is critical part of that.



Griffin Jones  38:02

Well, that succession plan, as you described, it makes filling senior positions a lot easier for two reasons. One is that if you're continually bringing junior people in, if you're continually bring lower level positions in, some of them are going to grow to be great senior leaders. So you, you have that pool to begin with. But then secondly, if for those times, when you don't have a senior leader to take from that pool right away, you still have that team in place that is much more attractive to recruit a senior leader if you have those folks. So it's it's a lot easier to recruit that talent for two reasons. You talked about that it can hit the p&l for a little bit. And you need to make an argument to the investors that it's beneficial for the midterm. So what are a couple of examples where you've done that, and you'd say, Hey, I've sat on your seat on the finance side. And I know that it's going to be it's not going to look great on the p&l for the next four months. But in two years, it's going to be amazing. And what are a couple of examples of that and what data did you use to make your side of the argument?



39:23

That's good question. The The best example I've gotten to that is when we centralized call handling, and patient inpatient handling. So this is patients that are currently patients of ours, where they would previously ring or contact each individual clinic for updates on test results or whatever it might be that they were, they were ringing for. And we were providing an okay service, but we know it could have been it could be better. And the reason for that is is the clinics. It's the laws of small numbers, right? So each clinic I only have four or five people that are dealing with that kind of request. And small teams have vulnerabilities, vulnerabilities of succession, sickness, you name it poor performance, they are exposed to small fluctuations that lead to a big impact on on on their patient service. So we decided that look, it'd be a lot easier if we centralize this, because then one or two people being off sick, or it can be covered quite easily by a much bigger, broader central team. And we can share best practice better, etc, etc, etc. So we decided to make that change, excuse me, we decided to make that change. But the, the way to do it in the most impactful, least risky patient friendly way was to actually build 80% of that central team, before letting any if the local team go for moving them into position. And that obviously came with quite a significant cost, because you're building up a team before you've replaced the other team. And then you're running them in parallel, and then you make in the final changes. And that was really about articulating the benefits to the board and saying, look, the ultimate benefits here are this. And it's going to cost us this much. And these guys are very smart people. And if you treat it in the language that they understand, which is I need to invest this much. This is my investment. And this is my return, then they can visualize that. And they just want to know, when's it going to happen? How do we measure it? What are the milestones, and that's very, then that's a very easy business decision to make. And I would argue that it's all very patient friendly as well, because not only are you ensuring that the experience whilst you're building, the team is a good one. But ultimately, we did this not to cut not to save money, it was done, really to provide a better quality of service to the patient at the end of the day.



Griffin Jones  42:05

My second New York Times best seller is going to be about pre selling and, and to what scope pre selling should fit into what constraints pre selling should fit into for the reasons that you're talking about. My first business fertility Bridge is a client services firm and was very much we're selling, delivering, selling, delivering, it wasn't it's not like a crazy, huge business. So we're able to do it. But gosh, it you know, it's it's a lot to do to sell, then deliver. And now building inside reproductive health into a trade media company, I can take my time more. And I'm building out a lot more of the delivery capacity ahead of time in ways that I wouldn't have in years prior where I would have tried to had that immediately funded. And for a couple reasons established, I feel that the concept is proven and other ways have built up that cash reserve to do it. So I'm the board that you're talking to. I'm the investors that you're talking to, in this case, because it's self funded, but I am really seeing the value of it, you know, we'll just sell a couple advertisers at a time here, we'll continue to build this system. And it there's no rush to, I shouldn't say there's no rush, we're moving quickly. But it isn't like we're having to fulfill something and we're building really building a delivery capacity is much greater advance than we would have in the past. And that's what you're describing. But it's very antithetical to, if you remember, oh, gosh, what's the Eric Ries the author of The Lean Startup, and that whole school of thought of don't ever create anything until the concept is totally proven? And so do you? At what point do you feel it's sufficient to say, okay, the concept is proven, but I really need to build out the delivery capacity before I start selling it there before I start having paying customers go through it. I think it really depends



44:04

on what it is that we're talking about. In the case of what I'm describing. We were able to trial, the service in one clinic first for a six week period to really hone in on the way it was going to work, what the pain points were, what the SOP should be, and then launch it multiple, multiple clinics wide. So I think have it in having the concept is going to be a combination of data intuition and, and feedback. And then you did try then for me, you run a trial period of whatever that might be low touch trial period. It could be that if it's a clinical service, you've heard Allison talk about care maps AI when she was on. If it's a clinical service that you're launching, there may be you do it for free for the first month just to get feedback and you understand how it's working. And then when it's working And then you start charging for it. It might be in the case of my example, a patient services change, where you do it in a small way to start with just to get that, get that feedback, get the get the process perfected, and maybe also to prove some of the business case, because it might be that the business case says that we're expecting 50% of people to do this. And if it's only 20%, then maybe it doesn't work anymore. And so you get that feedback, you get your prove or disprove some of those myths. And as part of that, and then you go with a bigger rollout. So for me, it's all about limited, limited trial periods to really then perfect what you're doing. And that becomes even more important, the bigger you get. Because the bigger you get, what would be a challenging one clinic becomes critical in multi site operations. And if you if we were to roll out a new system or a new process across 20 clinics, without really understanding the impact of that, we could have a big problem,



Griffin Jones  46:02

I want to let you conclude with the thoughts you'd like to conclude on. But before I do that, I want to tie back into the theme that I opened with of a new generation of CEOs, in many cases taking over for the previous generation who had founded their groups. And it's happening everywhere as that's happening in the UK, it's in India, it's in the United States it probably in most of the countries of the world. And so I was thinking of Gilbert Godfrey, you remember the comedian Gilbert Godfrey with the funny voice from Saturday live, but he was on the second generation of Saturday Night Live. And he said they were the cast right after the original cast of Saturday Night Live and everyone hated them because they weren't used to Saturday Night Live cast changing at that point, it would be like if somebody just replaced the cast of your favorite TV show with a new one that people weren't used to it and, and so they they got fired within like a year or two. And they said nobody liked them. And, and the the, and then the next cast was able to really take off and become the classics of Eddie Murphy. And the that whole cast of the, the early 80s. That's probably more famous than the first one now. And so you're the third CEO. I, you, you the Eddie Murphy and what's what's it what's it like to be the Eddie Murphy after? What's it like to to try to resume a legacy, I guess in leadership?



47:28

Look, I always think of myself as the custodian of the care brand. And I'm temporarily carrying the brand to the next stage. And I'm always incredibly respectful and in awe, really, of the of the bravery and the foresight of, of my founders, you know, they did an amazing job. And I kind of carrying on that legacy. But I think the challenges are different than what there were for them when they founded the clinic. And certainly the challenges of running a private equity group, over three countries were tiny clinics, is very different to found in a one clinic, in a new city. And so I think it's different skills for different challenges, different areas and different periods. And, you know, there's some uncomfortable truths that are, you know, it's really difficult when you've got 1000 people to know everybody's name. When you're, when you're the founding doctor of one or two clinics, you will know everybody's name, you probably even know what their kids names are. And so the the environment is different, and there's no getting away from that. But then it's about changing some of the things for the better as well. So one of the things that we are very focused on you talked about it earlier, is HR and making sure that we share in some of these benefits of being a bigger organization with staff and then I think people do accept the cultural change that's, that's going on. They understand it. And then yeah, and it's about remaining visible, despite the fact that we're 20 clinics, 1000 employees, absolutely trying to remain visible so that you are accepted within the organization is not just somebody that's running the business that no one ever sees, but actually they know me as as Dave, and that's really important



Griffin Jones  49:25

to me. What level of temporary is appropriate, it's a temporary custodian and and someone that is brought on as an executive of whoever the CEO of Mattel is now wasn't the CEO 20 years ago and likely won't be the CEO 20 years from now and that's fine. Then there is a tenure that seems to be just too short to make any kind of meaningful difference. So you see, lots of CEOs I look on LinkedIn is like, Oh, they're the CEO there for 10 months. What are they like a Gen Z intern? How Probably the CEO for 10 months, and then the CEO for 11 months over there, or, you know, two years and, and one of the concerns that people have with private equity with publicly traded companies with venture capital in the field is that there's churn, and there's the stripping of assets and selling it at a higher price. And then and then being gone. And five years, you've been almost five years at care. And that's, that seems like a pretty good tenure, what level of, of temporary is appropriate,



50:29

five years and three private equity firms. So, you know, I've survived survive that long, I think, I think for me that, you know, in any job you go in, and I think most people would feel that within six months of starting a new job, you've got a good idea of where you can add value and what you can do and how you can and how you can do that. And, and I've kind of been through two phases that I would say, you know, I came in as finance director, I had some really good ideas about how I can improve things. And I did that within the first 18 months. And then as CEO, I've kind of been through that period as well, where it was like, right, these are the top five things that I want to achieve as part of being the CEO of for care. And then I'd say, I've been through that. And now my, my period I'm going through with care now is we've we've got a really, really good UK business, and how can I establish that on the international stage? And that is given me growth and drive and enthusiasm to see how can we take what is a one country really successful model, then see how that adapts into other countries and other successes, and then one of my other big passions is building the team around me? And to answer your question directly, I don't think there is a prescribed time. But I, myself would feel that when I've achieved that international growth, and I've really got a strong team around me, then it would be right and proper for somebody else to have a go really, because I think no matter how good you are, there is a period where you've done the things that you wanted to achieve, and you maybe get a bit stale. And and I think I don't know what that lead time is. I hope it's not six years, but three years



Griffin Jones  52:14

after that. And that's when you're gonna retire. We'll see. Dave, our audience is fertility practice owners, physicians and executives increasingly from around the world, how would you like to conclude on the topics that we discussed today?



52:32

Thanks for giving the opportunity and, and hopefully, people have listened this far. So thanks for listening. But the way I'd like to conclude is that the US is very exciting market. And that's why there's a lot of private equity interest in the US. I think there's some really good players out there and some really good firms. But they've all got their differences. And what I would say is, it's really, I've worked on nearly 10 acquisitions of clinics now talking to doctors, spending time at their houses, spending time getting to know them, and really understanding them, every single deal is different. And every needs, people are different. And so it does worry me occasionally in the US about how many sales are being really process driven sales because it for me, I would say that if you're a doctor, you should really think about what it is that you want, or unknown, or I should say, what it is that you want. And if that's the biggest check, that's fine. That's totally acceptable. But in my experience, that's not always the case,



Griffin Jones  53:37

process driven sales not happening to that degree in the UK, in Europe. In your view, though, what do you think are the main differences? The main,



53:47

it depends on the process, first and foremost, but generally, yeah, in a process, you don't get a very tailored deal. It's a very off the shelf deal. And in my experience, you you often have clinics with three or four owners, and each one of those owners might have different desires for the future. Some might want to retire straight away. Some might want to be with a business for 10 years, some people want to do research and development. Some people want to be just business people. And it's really difficult for a buyer to be able to present an offer in a structure that's really tailored to the those individual people's needs and desires when you're kind of held off, but a distance with an advisor in the middle, not necessarily with those same motivations. So it really it's horses for courses, as we would say, in the UK and it you've just got to think through what it is that you want from a sale and and we pride ourselves, really and I personally pride myself so I'm really trying to understand what it is that the sellers want, and then try and come up with a structure and a way of working that that satisfies those needs.



Griffin Jones  55:02

Why do you suspect that that type of process sale is more common in the US than it is in the UK, in Europe,



55:07

I think the pace of change in the US is faster. You know, we've been going through a consolidation process in the UK for over 10 years, I did my first acquisition in the UK back in when I joined 2014. And we're still doing them now. So it's been a much slower process in the UK, whereas the pace of change in the states seems to be a lot faster. And I think maybe clinics are getting not forced, but are feeling the pressure to settle and move on. And that maybe leads them to stay where they are going with these very fast six week advisor led processes, which, like I say, it's horses for courses that might suit some people, but this is advisor



Griffin Jones  55:53

being the person that represents the sell side. Yes. And so normally, that they the Steelmen argument for that would be you need somebody to advocate for you. And, and so what's the drawback? No, no, it's



56:09

not saying that you don't need sell side advice. It's, it's the type of sales. So sales side advice is critical. And these advisors do an amazing job. But it's when it's a very fast six week process and pious beard winds kind of thing might be perfect for some sellers. But in my experience, what you'll find is that there's sometimes a misalignment after the sale, because you didn't really get chance to talk about what it is that you want and what it is that they want. And how can you it was very quick. It was a very quick process. And so this is quite often somebody's Lifetime's work, right, they spent 20 years building this business, why not spend a little bit longer, just getting to know who it is that you're going to be partnering with after the after the deal would be my main advice, really, to people. And then, as I say, my passion and, and cares passion. And having done lots and lots of these acquisitions over the years is to really understand what it is that people want, and then to try and tailor that deal to suit them.



Griffin Jones  57:12

Dave river CEO of care fertility, thank you very much for coming on the inside reproductive health podcast.



Sponsor  57:18

This episode was brought to you by Univfy Download Univfy’s free IVF conversion and revenue calculator Univfy.com/IVFpatientretention. 



Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor have the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest appearance is not an endorsement of the advertiser. You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice

179 Chat GPT Has Arrived In REI: Conqueror Or Collaborator? With Dr. Ravi Gada and Manish Chhadua

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.






Please Note: We recorded this episode two months prior to release, and Manish and Ravi have already been pinging me about changes that have happened since. I will do another episode with them because this topic is constantly evolving!


Chat GPT is here to change the future of your job in the fertility industry, or maybe even take it. Is this a stretch? Dr. Ravi Gada and Manish Chhadua discuss how Chat GPT and its predictive technologies has the potential to revolutionize is already revolutionizing the fertility space. And what may come next.


Tune in to hear:

  • Uses for Chat GPT in fertility clinics and the Open AI source behind it.

  • How Chat GPT is being used to share data with patients, aggregate data, how it may be used in the future to generate prompts and consult notes.

  • The elimination of scribes and schedulers.

  • How Chat GPT will be able to interface with patients to provide 27/7 availability and access to care.

  • Griffin push Manish and Dr. Gada about what the second and third order consequences will be from this development, and what significant long-term impact it could have on the future of REIs.



Dr. Ravi Gada:

LinkedIn: https://www.linkedin.com/in/ravi-gada-md-mba-a2307527/

Manish Chhadua:

LinkedIn: https://www.linkedin.com/in/mchhadua/
Website https://reuniterx.com/




Transcript


Dr. Ravi Gada  00:00

In the fertility space, what we're going to deal with is who owns the data inside the EMR. So, when we talk about regenerative AI and language modeling, we're talking about being able to talk back and forth with a patient, maybe summarize a chart, create a summary of a consultation and put a note in the EMR. But we also talked about in AI, this whole idea of helping predict outcomes for IVF, as well as dosing for medications for a cycle embryo growth and development and who owns that data.




Sponsor  00:31

This episode is brought to you by Univfy, email Dr. Yao at mylene.yao@univfy.com, or just click on the button in this podcast, email or web page for your free IVF artificial intelligence tips and strategies. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest's appearance is not an endorsement of the advertiser.


Griffin Jones  01:13

A monkey can do an IVF egg retrieval. That's something that more than one REI has said to me. That's a euphemism. That's not really true. But will we be saying that what Rei is can do today is like the intellectual capacity of monkeys, based on what's coming with artificial intelligence? That's the topic of today's episode, you might listen to today's episode and wonder is Griffin high? No, the topic of today's episode is exactly why I don't get high. I talked to Ravi Gada. Dr. Ravi Gada and Manish Chaddua. Both of Reunite RX niche is the founder. Dr. Gada is their medical director, Dr. Gada also practices at Dallas Fort Worth Fertility Associates, we talk about chat GPT, which many of you have heard of some of you may have not the open AI source behind it, we talk about the applications that it's having. In the greater context right now the applications that it's having in the REI practice, how it's being used to share data with patients, how it's being used to aggregate data, how it will be used in the future for prompts and generating consult notes, how it will replace the work of scribes and schedulers and nurses how it will be able to interface with patients as an avatar of you. Because of technology that already exists. Today, I pushed Dr. Gada and Manish To explain what they think the second and third order consequences will be from this and what the REI will do when half of the communication half of the tasks that they're responsible for today are done by artificial intelligence tomorrow, at least half depending on what length of time we're talking about. And if we're talking about a long enough period of time, does it become everything that an REI could possibly do in a way that they couldn't possibly add any more value over what general artificial intelligence can do? You'll notice throughout this conversation, we really tried to keep the conversation about the applications of what happens in the REI practice, at least for half of the episode. But there's almost no way to contain it to just that open AI is Chat GPT product is just the tip of the iceberg and it has implications for every single aspect of the human experience. I might sound dystopian or pessimistic when I'm trying to get Manish and Ravi to think about this during our conversation. I don't think I am I think I'm pretty neutral. I'm not making a value judgment if it's good, bad or neutral, but follow along as we discuss how this conversion of technology not only replaces workflow that happens in the REI practice, does it replace the concept of human production altogether. Buckle up. Don't even consider consuming anything that has cannabis in it and enjoy this conversation with Manish Chadduaand Dr. Ravi Gada. Dr. Gada, Ravi. Mr. Chaddua, Manish. Welcome to Inside reproductive health.




Dr. Ravi Gada  04:06

Good to be here.




Manish Chaddua  04:07

Nice to meet you.




Griffin Jones  04:09

Manish , do you know how many times Ravi has Monday morning quarterback my show and I get a text or an email something that I should have said or something I should have asked. I've always asked him to come on. He says no, I don't want to rock the boat. I don't want to shake salts. I don't want to stir the pot. And finally I got a text from a couple like a month or two ago saying okay, I got a topic let's talk about yet. GPT. And I said all right, great. This'll freak people out. And he said companies government I said Yeah, so I want to freak people out about chat GPT. But we were speculating before we even started recording how much of our audience knows what chat GPT is how many of them know about open AI the platform that it's built on? So why don't we start Elementary and just give context for what we're even talking about? 




Manish Chaddua  05:00

I think a lot of people have read a handful of articles maybe about chat, GPT. But you know, it's an endeavor that kind of started probably about five years ago. It's often invested heavily into it. And then, you know, really just back in November of this year, last year, they basically launched this first kind of forward-facing view for consumers of what exactly it's capable of. And so the founders behind it are, you know, a handful of guys, Sam Altman, Peter Thiel, Elon Musk, I think are some of the original core for it. But since Microsoft has invested upwards of $10 billion into this product,




Dr. Ravi Gada  05:38

well, and Griff just, I don't know if people know what I mean, Sam Altman is the former CEO of Y Combinator, Peter Thiel, former founder of PayPal, Elon Musk, obviously everybody knows. So it's got some pretty big backing behind it.




Griffin Jones  05:54

People know those names but tell us about what Chat GPT is doing.




Dr. Ravi Gada  05:59

Chat GPT is an AI language modeling platform, it's probably considered a SASS platform where users can go onto the web, create a login, it's absolutely free to use, there is a paid version of it that you get a little bit more priority. And you can ask it just about anything. And it has over 100 billion different data points. But you can ask it, you can just talk to it. If you're like, Hey, how are you today and go through a conversation, you can ask it? What's the reason for having an Hmh of less than one, you can ask it to draft legal documents that you can ask it to write a poem. So and really, it puts this together and you can iterate on it back and forth to get to the point where you're happy with the answer, copy paste, but it into your platform and use it a lot of people are saying it will be used to augment the workforce and make our lives easier.




Griffin Jones  06:54

Manish, How does that work? Like how is Chet GPT using open AI to be able to do that?




07:01

So chat, GBT is called the term that's being used for it as generative AI. And so what chat, what they've done is they've basically created, you know, in the term is a caucus of data of about 170 billion data points, which is articles, publications, all sorts of data points across the internet, they stopped collecting that data in about 2021. And really, the way that it works is actually through algorithms and just math, it's predicting the probability of the next word or the next most likely word in how it's generating this text. And so that's kind of the clever thing about it is that it's this large, large data set, it's able to basically look at that data set, and then predict the profitability of the next word. And that's how it turns into the text that gets outputted when you're asking your questions and the context that it actually receives when you follow up with that question, and things like that. So it's a predictive model,




Griffin Jones  08:01

Doctor Gada, give some of the use cases that Chat GPT is being used for what are some of the funky ones that you've seen, one of the funky examples that I've seen was, like, talk about a certain type of story in the tone of comedian Tim Dylan, and it was the comedian, Tim Dylan reading it. And it was pretty close. And even he says, like, wow, this is, this is pretty close. And it clearly wasn't there yet. But it's more than just write a poem or write an article, you can actually say, write an article for this certain type of audience or write it in the spirit of x. And so what are some of the wacky examples that you've seen?




Dr. Ravi Gada  08:43

People are predicting this year, chat GPT, or any other language modeling system is going to write a screenplay for a movie, it's going to give it some input data on what type of movie at once and who the characters are, it's going to write the movie from start to finish finish. And they're going to take that storyline and put it into an animated AI platform dollies for pictures, but there's some animated ones in the background, and it'll create the animated movie and that by the end of this year, we'll have a movie in which the screenplay and the animated movie are all done by AI with minimal human input. Wow. So even




Griffin Jones  09:21

the characters, the action of the animation is going to be created by artificial intelligence.




Dr. Ravi Gada  09:27

Yep, completely based on the language of the screenplay, and it'll make all the action of the characters, the voiceover to voiceover as well. So you can there's voiceover you can do now, so I could probably record all of your podcasts, uploaded it to chat, GBT right what I want Grif to say and replay it, and it's going to sound like I'm doing a podcast with you. And we can call it something else.




09:48

Well, I'm going a step further from that they can actually model based off of a handful of pictures of you an actual animation of your face and have that talking as the actual animation for that. Voiceover so that's so they can mimic like real life people and things like that. And that's not just GBT. But that's other AI solutions that are out there.




Griffin Jones  10:08

Sure. What is that? Is that the deep fake? What is that?




10:12

It's related. I mean, it's in that vein. Yeah, exactly. Yeah.




Dr. Ravi Gada  10:15

Deep fakes, probably the most popular one.




Griffin Jones  10:17

Is that a different type of artificial intelligence? What's behind that?




10:23

Yes, sir. I don't know a whole lot about what's exactly behind that. But it is using AI to basically evaluate facial expressions and things like that, like deep fakes, specifically takes my facial expressions, and it superimposes your face onto it. There's other versions of that that basically will just take text and known kind of vernacular and how mouths moves and things like that, to basically create video or animations of a person actually talking.




Griffin Jones  10:51

Okay, well, I could just totally dive into this part where I'm deeply concerned about someone making a podcast episode.




10:59

That's a really weird edge case, or not weird, but just kind of scary, is that even hackers are using chat GBT to generate clickable content so that way, they can send email blasts out and they'll just ask it things like, hey, create a email that's basically has a link in it, that's the most likely to be clicked by users. And it'll actually generate and so this is another edge use case where it's like, okay, well, you know, the malware the ransomware type of folks out there using it to help move their cars.




Griffin Jones  11:32

Well, I want to come back to this and talk about what we think second and third order consequences might be of all this, but let's talk a bit since this is, after all, a show for Rei is it isn't Rogen were talking to fertility specialists and the people that own fertility practices? What are the applications that open AI can be used in the REI practice at this time?




Dr. Ravi Gada  11:59

So I think at large, right, we've, we've seen in our space companies that come in just using AI for data mining for embryos, look grading eggs, grading embryos, there's companies trying to predict what's the outcome of an IVF cycle. But we haven't really seen too much movement in the linguistics modeling or the language modeling. So in an REI practice, could you create a chatbot that basically communicates back and forth with a patient answering simple questions. So if a patient calls, or has a question about what's my Hmh level? Or what's this thyroid function test, could could a language model reply back and forth with that patient just enough to answer as many of their questions as possible? In healthcare, you want to be very careful in what we call follow up criteria. So if the if the bot doesn't know the answer, then say, Hey, let me get one of the nurses for you or one of the doctors and then someone picks up the conversation from there. But you could think about that in a way where patient has free access or 100% 24/7 access to a chatbot that's been trained by us in the REI community. We've given all the language the data points, the conversational pieces to have. So that's a use case. Interestingly, I did a did a thing the other day I put write a male male couples gestational carrier contract, and it spit out a gestational carrier contract immediately. And then I said, Well, can we add language for what happens in the first trimester if there's abnormal screening, postpartum does the gestational carrier provide lactation and milk for them and and it added all these sections in there along with by the way, an exhibit page to add the financial conditions of all of these things, so I can have it write contracts for third party reproduction pretty easily. I had a patient asked for a work excuse the other day, and I had chat GPT write a work excuse after an abdominal myomectomy for six weeks, and it wrote it for me. It leaves blank so you know template so then you copy paste it and then you add the patient's name, sign your sign it and send it.




Griffin Jones  14:12

Let's talk about the EMH level example for a moment, the thyroid function example for a moment, how would we know if the bot gives the wrong answer?




Dr. Ravi Gada  14:21

So this is the part that gets complicated, right? So what's interesting is there's plenty of companies today that have language modeling, ai, ai ai, so chat. GPT is owned by open AI, open AI is primarily going to become a Microsoft based company. Recently, Facebook launched one called llama and then Google launched one called Bart and so everyone's going to have a version of this. You have to then take their AI language modeling and input your own data set. So perhaps that's recording the next 1000 hours of calls with nurses and physicians with their patient. inputting that data. And then running tests to see is it doing what it's supposed to be doing? And if it is perfect, if it's not, you have to give feedback to the system always. And that's how it's why it's called machine learning or regenerative learning is it has to learn from itself. The patient either has to tell it, it's wrong, the nurse has to tell his strong, but you've got to feed that system enough to be smart enough to give the right answer and smart enough to know when not to give an answer. But that's going to be the biggest challenge in our field is making sure it doesn't overstep its bounds.




Griffin Jones  15:33

And so at what point do we expect it to be able to be a better judge than a human being?




Dr. Ravi Gada  15:41

I think in some cases, we might already be there in certain language modeling. I mean, when we in you open up your Gmail, or Outlook, and it practically finishes your sentence for you when you're typing up an email now, and sometimes I'm like, well, that's better than I would have wrote it. So let's just go with that. But in the healthcare space, I think we're I think we're a bit of ways I think we always are later adopters, for new technologies for that reason. But if I had to guess, I mean, we have to be three to five years from being able to really, I hope within three to five years, where they're where we can leverage this type of technology.




16:14

And the biggest challenge is going to be what Robbie's talking about this Fallout criteria. So when we think about AI, and basically, you know, creating the answers are basically predicting what the answer should be. The probably the, the hardest part is going to be that aspect of just knowing when not to answer and AI is not there yet, or doesn't seem like it's there, which is why a lot of stories are online about how they're tricking chat GPT and providing wrong answers to math questions or, you know, doing a handful of other things like that. So that's probably going to be where, you know, some, the physicians in general, will view this as a tool that helps them get to the answer faster. But it's still, you know, we're far away away from between us getting to the point where we can blindly trust that to do that.




Griffin Jones  17:06

Have you read anything about the regulatory bodies or the agencies thinking about how we're going to regulate this either from ama or from Fe cog or from is anybody talking about this? Rob?




Dr. Ravi Gada  17:19

I don't think anybody's talking about him. I was listening to a couple of podcasts about it. So in healthcare, it's not interestingly Moniece mentioned to me earlier today, chat, GBT did certify that their HIPAA that they have a HIPAA compliant API version to it. I don't think any of the society organizations are talking about it. Even in this sense of copyright. People haven't really quite figured out when chat GPT pulls language from the internet, essentially rewrites that language and spits out an answer. It's not giving attribution for where that came from. And so there's even concern that could chat GPT ultimately get stuck in lawsuits with copyright? And are they just rewriting someone else's language or or verbiage that's out on the internet without site citation of credit? And Google does it right you type a search? It gives you an answer. But there's a link to where it goes from they might summarize a little bit in the in the description part. But ultimately, it gives credit through a link which chat GBD does not. So there's some people looking at this, but I mean, no society organizations from a medical standpoint, no, I don't think anybody is even digested what this technology means




Griffin Jones  18:31

until they hear this podcast. And they're like, Oh, crap, we have to have a board meeting.




18:36

And one of the counter arguments to the copyright thing that Ravi just brought up is that, you know, do humans in general do anything different? Are we just basically absorbing information and data from a variety of sources, and then basically mimicking what we hear with some amount of, you know, how much innovation is actually being produced? Out of what we regurgitate? Right? Some attribution




Griffin Jones  18:59

and some innovation, but very often isn't even possible to totally attribute everything because like the machine, you might be saying, in this case, money's we're aggregating and it's an amalgam of everything that we've consumed. But I was I was going to ask you that question about intellectual property, too. And you brought up the example of Google Ravi. And I wonder if if case law is still been established about that? Because sometimes I think like, is that enough when a creator is putting out information or creating something, and Google just kind of takes it and they put it on a Google search? And yeah, they give it a little bit of credit, but very often, what does the Creator actually get from that credit? If that person gets their answer right there in the search, they don't ever have to go to the creators website. They might see that little URL at the bottom, but they're pretty much just getting their answer from Google. Is there any kind of case law that, you know, Manish that has been established? Or is there are there battles going on about this




20:07

definitely is something that's been brought up even just about how the way Google works. Now Google gets a little bit of away with it, because they are actually providing that attribution. And I think that's where chat GPT will be very different. Because, you know, it's not the Texas generating is somewhat unique, but it's not actually sourcing that direct place of where the data is coming from. Even Ravi and I have had conversations about this as well, just to say, you know, here are the different differences. And then, you know, Google is a little bit different of an animal as well, because it's giving that attribution, it's giving hope to those creators to actually get the clicks or get the referrals. So I think it's a little bit of a different scenario altogether.




Dr. Ravi Gada  20:48

But there, but there is, there is case law for this. So there is something called fair use for copyright. So fair use has been established that our case law underneath that there's four criteria for violating fair use, but one of them is not citing the person, but it has to affect their ability to monetize. So if you have a company that has a bunch of articles about fertility, and you're regurgitating their data and putting it there, and their whole business model is to get links, have people click on that? And then ultimately buy something or lead them down something, then? Yes. And that's where Google pays people for that link. And so there is it's called fair use. I mean, I don't know that it applies to copyrights. Specifically, it's not going to apply to what we're going to deal with in the fertility space. I think in the fertility space, what we're going to deal with is who owns the data inside the EMR. So when we talk about regenerative AI and language modeling, we're talking about being able to talk back and forth with a patient, maybe summarize a chart, create a summary of a consultation, and put a note in the EMR. But we also talked about in AI, this whole idea of helping predict outcomes for IVF, as well as dosing for medications for a cycle, embryo growth and development. And who owns that data? Is that the patient is that the clinic? Is that the EMR? Is that everybody? And I think there will be a little bit of information that comes out from probably not the fertility space, but probably more on a higher level of internal medicine or diabetes of who owns this data.




Griffin Jones  22:27

I wonder if this affects people like me even more so than it might the general public and that those that are in deep niches, and are based around information are in deep niches, part of the reason why anybody picks a niche, whether it's a client services firm, or media company or software company is so that they're delivering specific needs to a small group. And that's where they that's the entire reason why they do it. And if something can just say, hey, take everything that inside reproductive health has gathered and created from original sources, then it could be the small niche companies that are most vulnerable, don't you think?




23:16

Yeah, I mean, content creation is something that's going to transform quite a bit. I mean, even if you look at the way, you know, traffic gets generated, and Google and even beings a algorithms work right. Content Creation is like, been the pinnacle of how they judge what's what's good, what's not what's new and fresh. And so that's definitely a large area of impact. I mean, there's, there's sub companies from chat GPT that have already been created that just create copy, and they create everything from sales, copy, marketing, copy, blog copy. So that's definitely distinct part of I wouldn't call it a threat, but a possible, you know, a rethink of that approach of copy creation or content creation.




Dr. Ravi Gada  23:59

I think the niche markets will get saved in this because when I look at health care, people focus on cancer, diabetes, hypertension, obesity, and fertility, and very small sectors get overlooked. And so all of these companies I think, are going to be focusing on the big three, you know, in terms of hypertension, diabetes, obesity, and then add cancer, and infertility kind of gets overlooked. I think that's why actually, as a field, I feel like we're very technology deficient. We don't have enough technology infused into this space, and maybe will be saved. I don't know.




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Griffin Jones  25:57

We talkedabout a couple of the applications that you're using right now what applications do you expect that aren't quite there yet, but that open AI chat GPT will be able to do in less than three years.





Dr. Ravi Gada  26:11

Imagine a day that we're I'm sitting in a consultation room with a patient, there's a TV screen behind me here. And I say well, let's take a look at your Hmh level today. And on the screen, it hears me say that and pop to the h a m h up on the screen behind me for the patient to see that. And then I say, you know that's numbers normal, you know, that should mean that you have a good ovarian reserve. We also do a follicle count to look at that. And here's me say follicle count from your ultrasound. And it puts that up on the screen. And I have this now interactive conversation with the patient. They're asking me questions, we're going back and forth through a return visit or new visit. And at the end of that visit, we walked out of the room, I hit done on the recording device. And it generates the entire consultation note immediately on its own because it's regenerative language modeling gives me You know, I can then sit at my desk take 30 seconds to read it finalize it done, by the way, any edits that I make to that note that I didn't like the way it writes, it's recognizing that I edited it and and learning from that. So I think at the highest level, you could look at that you could look at it basically, you know, every six months, every three months, it reads the entire chart for a patient and summarizes it in a note on a three month update or a weekly update depending on what cadence you want to do that in. So there's things like that there's things that I could have it recording all the calls that my nurses do to patients, right, I rely very heavily on my nurses to communicate back and forth with patients. And I can and the language model can tell me if there was inaccuracies being presented or something that is different than what I would have said based on its understanding of the conversation. And then we can we can retrain that nurse, we can improve things, you know, it goes beyond nursing, to imagine the day that all of these things are just used as tools to make us better, more efficient. And ultimately, it will probably take over half of the I wouldn't say conversation but communication that we have back and forth with our patients.





Griffin Jones  28:24

At what point might we expect to see the avatar Doctor Gada, having that follow up. And so if all of those things are just different data points, and it can compare it to all of the data points from every piece of scientific literature, fertility and sterility is ever covered. And everything from all of the medical colleges, if it can just deliver that type of information, and we can use your video we can use your voice at what point are patients just seeing a virtual Doctor gotta





29:00

so I think the humanity and US will fight that pretty pretty well. So I think if you look at telemedicine, a lot of things like that, I still think the preferences is face to face communication, I don't think you can replace that for some people. Right. And I think for places where we're underserved pay at places where we're trying to get into that aren't getting quite the availability of health care. I think those are the areas where you'll see this kind of really explode or really thrive is to care for patients in in those particular areas.





Dr. Ravi Gada  29:32

But I mean, I've talked to Manish about this you know we have a lot of pilot projects in this area of where where will this technology take us and how do we get in a lot of it's in the datasets that are fed into the system but when I do think does the day come that you asked the patient would you like to see the human doctor or would you like to see the avatar Doctor initially or virtual care models are already there today. Many patients are going online and wanting to order their her own tests and get their information at home or through virtual care. So I think there's a version of it today, I think there's going to be a more sophisticated version of it in the future.





Griffin Jones  30:10

I'm a little skeptical on Manisha is hope for the humanity aspect. I think people want the humanity when they feel that the robot is insufficient. So the reason I yell into my phone when I'm talking to the the banking teleprompter is because it doesn't understand that I'm saying, talk to an agent or review account balance. But if I actually could do that as easily as I could correspond with a human being, I think it has more to do with convenience than humanity.





30:42

Yeah, for sure. And grip, I think my my point of view on that is more for general, for healthcare, I do think fertility is a little bit different, because of the age of the patient and kind of, you know, the fact that every fertility patient coming through as either a for the most part is Millennials or younger, right? You definitely could see this avenue of I'd rather text with my doctor than, you know, talk on the phone with them, or, you know, have to go and show up at a clinic and actually have that face to face interaction. So I definitely could see that scenario.





Dr. Ravi Gada  31:13

You think about this, there's a YouTube video out there, if you type robotic reenact the Moses of bow, using artificial intelligence, there is a cadaver. So it's a pig model of a robot, taking bow and sewing it back together without any human doing it and it healed intact. And then obviously, they checked it sacrifice the cadaver and checked it. And so, I mean, if we're getting to the point where cars can drive themselves, robots can do bowel reenact the most surgery on their own, we will get to the point where communication back and forth with the patient or consumer will get there. The question is how far right do you get to the point where you just do the intake form? And asking a few questions for clarification? Or do you deliver lab results deliver? Do you deliver positive and negative pregnancy tests and that way? That's the part is how far will it take it? I think it's going to go. If you fast forward 30 years from now, there's going to be a way different version of doing this. The question is in the next three to five years, or while we're all around, how far are we going to get?





32:17

And that's absolutely right. Like you take any technology, any innovation like this, and it's all a matter of a timeline, you assess some rate of improvement, and every tech pundit will say that is whatever the rate of improvement you select, that means at some point in time, you know, the technology will surpass the reality.





Griffin Jones  32:36

m&e, as you said, this has been in the works for some time now the technology behind chat GPT. But it seems like there has been an inflection point recently though, no, like, just how good chat GPT is itself. And then I practice with it. And a couple other like, think of translate for exam I, I don't remember the last time I used Google Translate for language, but it used to suck and not too long ago. And recently, I when we were covering the KKR story for buying ie vrma. And their only media coverage was in Spanish. And I speak Spanish pretty well. I put it into Google Translate to see and it was good. I like almost as good as as a native speaker who had been natively raised in both languages. So what's the inflection point when he's what happened recently?





33:28

Yeah, so this is common, right? This is common in a lot of technology, whether it's the smartphone or the internet, or, you know, even AI. And really, it's a byproduct of technology from 1015 20, even 30 years ago, becoming more accessible, less expensive to use, and basically more awareness, right? So you take smartphones from, you know, back in the late 90s. And they existed, and they had a lot of functionality. But it wasn't until the advent of the iPhone, where it really was the right time in place. And the cost equation made the most sense to where it can actually rapidly grow inside of that. And by the way, my background is telecom. So that's why the analogies there. But then pass that chat. GBT really is the first very consumer facing version of an AI model that showed the rest of the world everybody, including, you know, guys, like you and me, as well as you know, just college students and everybody else in between, right, what the capabilities of AI is. And I do think that AI has been in place for a long time. I mean, it wasn't, it was a number of years ago when AI beat, you know, IBM Watson mini in a game of chess. And this is just that acceleration. And I do think in AI, right, if we look at any of these revolutions that have happened, or major disruptions in technology, you know, it keeps happening faster and faster. And so So I think chat GBT has really opened everybody's eyes to what's capable? And now, all the thinkers and innovators are out there? Basically saying, Oh, I didn't realize we were this far along. How can we employ this as a part of, you know, a core model? Or how do we adopt this and find out what the right solution is that's really chasing this already, and integrated into our workflow.





Dr. Ravi Gada  35:18

And Griff real quickly to add on that. So the inflection point was I don't know if sometimes we will realize Chat GBT launched in November of 2022. So the inflection point was the first real launch of a major language model. And it obviously caught fire. And that's why we're all talking about it, or a lot of people are talking about it, interestingly, in that, but it was founded, I think, in 2019, four years, something like that about four years ago. And they've been working on it up until now, interestingly, post chat GPT launched, let's call it circa November of last year 2022. That put a lot of pressure on Google and Facebook to launch their versions. And so Google launched Bart, and they did a commercial about this. And in the commercial, Google asked, or someone asked the chat bot, to tell them about the James Webb telescope. And it was listing some bullet points. And the last bullet point said that the James Webb telescope was the first telescope to take a picture outside of our solar system, which was actually false, it was actually not yet planet and people picked onto that. And as soon as it did, Google's actual market cap value dropped by $100 billion that day, attributed to this error, because everybody said, their language model and their regenerative AI is not as good as Microsoft's, and they're not ready yet. And it lost some around seven to 10%. Market cap $100 billion because of that, but I think chat GPT launching in November is why we're at that flexion point today,





Griffin Jones  36:52

to the point that is a can take over half of communication that's currently happening between the REI practice and patients right now, maybe more than half so when that happens, Rafi not if because it will happen. It's only a question of time when that happens, what is the RBIs role going to be?





Dr. Ravi Gada  37:12

And you know, I mean, I think people worry about this a lot, right? People talking about not just the role of the RBI, but the workforce is these are these technologies going to replace the workforce. I mean, whether it was the calculator, whether it was Microsoft Word, whether it was, you know, all these different technologies that keep making us better and better. But we talk about this all the time in our field, that there's a under underserved population, there's, you know, we're at the tip of the iceberg. Maybe we're only meeting five 10% of the populations need. Does this actually make us better? Ultimately, we're still proceduralist we still do a lot of procedures in surgical procedures, egg retrievals, embryo transfers, IUI. Guys, so I hope or I think this is not going to replace the average ra i think it's going to make us more efficient. I think it's going to make our nurses more efficient embryologist more efficient. But you're right. How does it allow for us? And we talked about how many are the amount of retrievals that an REI can do in a year. And beyond that point, there. It's it's not beneficial maybe to the patient or the ER, and it depends how many nurse practitioners do you have underneath you? How many nurses? Well, this is going to be another adjunct to that technology have an honestly a checks and balance. I mean, imagine the day where we have going into an IVF cycle. And I'm going to do for the physicians and nurses that listen to the podcast, a Lupron trigger. Well, there's certain things for Lupron triggers that you want to know you want to know that that patient has regular menstrual cycles and that they have a normal FSH level. And so the second you order a Lupron trigger, that the that the AI actually scours the EMR and actually pings you and says, Hey, I don't see an FSH level on this patient. Are you sure you want to order a Lupron sugar? And I say, Oh, I'm glad it caught that. Let me order a FSH level real quick and make sure. So I think it'll make us more efficient. It's, you know, replacing us I think we're all going to be replaced one day, you know, whatever, whatever, you know, sector you're in, you're gonna get replaced 100 years ago, everybody was a farmer, or at least knew somebody was a farmer. Today, I don't really know that everybody can say I have a first degree relative. That's a farmer. So machines have already replaced, farmers machines have replaced manufacturing jobs. And that's the worry about this type of AI technology. It will replace jobs, but it will also create jobs. I mean, we didn't have the jobs we have today that, you know, that didn't exist 100 years ago. In fact, I don't know what the population of the US was 100 years ago. Let's make it 100 million people. Today were 300 million people, no manufacturing jobs, very few farming jobs, and everybody's still employed. So there will be new jobs created. Maybe we'll figure out newer ways to help people get pregnant, but things that are replaceable at Everybody should be looking at saying, you know, how do we either make ourselves better to stay ahead of it? Or how do we use it to, you know, augment what we do today?





40:09

And there's there's a lot of people out there far smarter than us that have kind of pondered upon this question as well. One of the other things that I think is kind of changed recently, is initially they thought a lot of low skilled labor would get replaced fairly quickly by automation and AI and things like that. I think chat GPT tests that a little bit and saying, Hey, listen, well, you know, if your job is sitting behind a desk at a computer, basically, replying the emails and doing things like that, there's a lot of risks there, probably more so than a surgeon, or, you know, even a mechanic at that point in time. So I think that's what it's changed kind of some of the view of what would get replaced by AI first, but I do think we're still a fairly long ways away from that, like, years, at least,





Griffin Jones  40:56

well, for now, and I do want to talk more about that. And we'll definitely end on a note where we're really freaking people out, but, Robbie, I want you to think a little bit about what it is that the REI will be needing to do in these coming years as Chat GPT gets an AI in general gets more sophisticated, like how I'm envisioning it is there's human Gada overseeing a hunt the capacity that robot Gada can do and robot Gada is helping to treat 100 patients and human Gada just needs to oversee robot Gada or is that not the right way of thinking about it? Because the human will soon not be?





41:38

Grip? I think the jury's still out on whether or not Robbie's a robot or not.





Dr. Ravi Gada  41:43

It could be it could be, do you wanna see dr ga da, or Dr GA D Ay ay ay.





Griffin Jones  41:50

Oh, it's already there. And and so what's the relationship supposed to be? Yeah,





Dr. Ravi Gada  41:56

I mean, I think ultimately, that relationship kind of goes back to, you know, we already use or have our staff help us accomplish what we accomplished in the day, I don't accomplish in a day, you know, very much if I don't have a nurse, an embryologist, a medical assistant, a billing person. And this will do the same. I think that, but I do think you know, we've managed to have talked about there, I'd love to do a commercial where I have four consultation rooms running with a iPad in there that's actually has my own avatar, speaking back and forth with that patient, one patient, it's their new patient console, the second room is their return visit with their lab results. And the third patient is coming back for another FET after a successful delivery. And all the while I'm actually over in the operating room doing the retrievals all day. I mean, so that day is coming. Now the question is, is that coming tomorrow? No. Is that coming in the next three to five years? Probably not? Is that something that we can work towards in the horizon of a 10 year type cycle? I think so. I mean, I know that might not sit well with some people. But I think you have to embrace this technology. We are looking at this very heavily. We're investing a fair amount of resources to figure out how to do that. And I think that the people that do will do well, I think the people that resist it may do well. But I think there's a high chance that they're not going to be able to be as efficient if they don't adapt to technology, which is the story over the last 100 years.





Griffin Jones  43:30

You talked a bit about it's some of this like data entry type of work that is most vulnerable. And I was hearing one expert on this topic talk about that it's actually more white collar work that is vulnerable rather than blue collar work because blue collar work tends to be more manual. But Manish when are we going to see an intersection between robotics and this type of AI because once that happens, then we don't need human God at all, once we have a robot that can do the very sensitive maneuvering in surgery that the best surgeons can do right now. And we have the artificial intelligence of all of the data points gathered from every surgery ever electronically recorded. When can we what progress are we seeing towards robotics and artificial intelligence? converging?





44:31

You know, it's actually something that's, that's familiar, before even AI right, it's the separation between engineering and technology or software. Right. And so this is I think, why we're seeing this is because replacing things that are soft like on a computer or something like that becomes a lot easier once you can get over a kind of the intellect or the brain of it, right? The biggest issue with robotics right now is probably the expense and so when In the cost of robotic arms, robotic equipment and stuff like that, that's reliable and high precision and things like that start coming further and further down. That's when you'll see this kind of cannibalize even those types of industries. And so that's where I feel like, you know, this low skilled or blue collar laborers, you said it, you know, as a little bit more protected, because the cost of those robots has not come down. And the functions that they pervert perform, and the accuracy of what they do, just isn't quite as inexpensive as, you know, your email solution of being able to message back and forth with patience or something to that regard. So it's going to happen, but it's just, you know,





Griffin Jones  45:42

so maybe there's a silver lining to all of this supply chain crap that it's slowing down the inevitable





Dr. Ravi Gada  45:49

grip. I don't know. Are you old enough to remember the Jetsons? I mean, that's where Yeah, remember





Griffin Jones  45:53

the Jetsons Flintstones crossover?





Dr. Ravi Gada  45:56

Yeah. So you know, I mean, imagine I mean, the Jetsons is looking forward to, obviously, if robots robots replace what we do, and we work, everybody's concerned on what would we what maybe we start enjoying life again, you know, we worked so hard, we, you know, is a society. And I'm not talking about just fertility, I mean, globally. And maybe we actually, you know, a 40 hour workweek becomes a 20 hour workweek. And we actually are able to read and spend time with family and travel. And maybe I mean, robots taking over and doing certain things. I'm not saying they're taking over the world. But maybe we get back to the point where society actually has time to do the things we do rather than being in this hamster wheel that we are in today.





Griffin Jones  46:38

Before it does, what other applications do you see elsewhere in the fertility industry and quote, so you talked about the applications that can happen in the practice between fertility providers and patients? But where can what other applications are we seeing right now with open AI, if any, in the fertility industry, and what more should we expect?





Dr. Ravi Gada  47:01

Yes, I don't think we're seeing I mean, I haven't seen it, I tried to keep a pretty good pulse on what's going on. I haven't seen it. There's some chat bots that are out there. But overall, in terms of chat, GPT, I don't think so we've seen it in obviously, in the lab, there's a lot of work being done to robotics and, and automation and AI. But what's interesting is, I don't, I think also no one in the fertility space, or even a lot of other spaces are going to actually be able to build their own technology on this, they're going to have to leverage I mean, think about Microsoft, Google, Facebook, Amazon, few other companies, I'm probably leaving out, but they have the best of the best, the brightest or the brightest, and essentially unlimited budgets relative to ours to do this. So a lot of this is going to be creating API Interfaces into their technologies. And using our datasets. I wouldn't be surprised if the EMRs that are out there are looking at this today, right? The electronic medical records, they're fairly technology forward, they are probably looking at their datasets, because they have actionable datasets. You asked me hey, you know, Hey, Ravi How much does DFW fertility associates? What kind of data do you guys have to feed into Chad GPT. And I've looked at you and say, I haven't even I don't have data. Like, I haven't started gathering that. But maybe I should, maybe we should start recording every conversation we have in the office with a patient and with each other, myself and my nurses, myself and the embryologist to feed this dataset, and is one individual, clinic or user or even an MSO going to be able to create enough data, perhaps but but likely not, it's going to require a collective effort amongst the industry. So I don't think we're there in terms of that. I mean, like I said, there's the earlier stuff, I was telling you writing a letter writing a contract for third party reproduction. But in terms of the high level stuff, it's got to be a concerted effort of gathering that data, putting it in, and then really, ultimately, you know, garbage in, garbage out. So if you put garbage data in, you're gonna get garbage data out is what that term is. But you've got to do that, then you've got to test the model over and over and over again, because in healthcare, we demand 99% excellence, right? In other industries, they might say 80% lunch, this, you know, we've all talked to a, a answering machine bot on a customer service line, they'll get to 80% and be satisfied with the quality of that work. We have to exceed that above 99%. So no one's there yet, but the question will be how do we get there? I think that a lot of people like us and others are looking at this. And I think that it's around the corner. If you ask me what does around the corner mean? I can't tell you the answer.





Griffin Jones  49:54

So I was going through Dr. Rudy Giuliani's workflow with her and I How she did 1300 retrievals last year and I was thinking of each of the points, she was talking about listening well, I could impact that I could impact and I told her, I said, You should listen to this episode that I'm going to record with Ravi and Monique, because she was talking about her scribes. And I was just thinking your scribes are gone, man, they're not they're not going to have a job in a couple of years. There's no way in schedulers to right.





Dr. Ravi Gada  50:23

Yeah, yeah, exactly. Or are their job changes, right? You know, they, you know, they either they're either gone, you're correct, or it changes, right. So we still like concierge service, right? So they, the bot kind of does that. I mean, Google right now, I think has a platform that you can order a pizza now through a bot or make reservations at a restaurant. And it'll actually if the restaurant doesn't have something like open table that you can go online and do it will call the restaurant and make the reservations for you and interact with the hostess without, without a person, it's a robot talking to a hostess. So those jobs will be either replaced or used in a different way.





Griffin Jones  51:03

Sometimes those applications come and they circumvent solutions that you would think need to happen, right? So for one of the things that we've been saying for many years is that millennials don't want to talk on the phone. But Gen Z absolutely won't talk on the phone. So you guys have to figure out your scheduling, you got to figure out this digital scheduling as well. Maybe you don't, because this Gen Z person can just input into chat GPT called the fertility clinic and make an appointment for me.





Dr. Ravi Gada  51:34

Yeah, that'd be ironic, as we keep focusing on how can we get the clinic to be the Chatbot. And we find out that the Gen Z is actually or the chat bots, and we're still interacting with them on the human side? Well, unfortunately,





51:45

they're not gonna go to the metaverse to schedule appointment anymore. So





Griffin Jones  51:50

well, it's just kind of one of these principles that you think of that we often it's, we have to build a certain type of infrastructure. And there were many countries, for example, that never really built out a telephonic infrastructure never had landlines at scale. And that was probably in their government central plan that, okay, 10 years from now, we're going to build telephone poles and have the wires out to the rural countryside. And they just never had to do that. And so there can be a number of applications that we're thinking of, for artificial intelligence that just circumvent the need for us to build out some other kind of solution.





Dr. Ravi Gada  52:31

So the other day I took I had an Excel sheet, it was a financial Excel sheet. And I took it and I was just curious, because I had heard people were doing this, I copy and pasted it, I didn't format it. And I thought what happened, so I just copy pasted into chat GPT, it looked awful. And I hit submit. And it summarized the Excel sheet for me without even having cells or columns or anything, it was very oddly formatted. So imagine taking the entire data set that we have for IVF patients and outcomes, and just dumping it into this thing. And just at first go saying, What do you think of this? Or tell us in patients less than with a Hmh? A 42 year old with an AMA H of 1.2? Whose BMI is this? Who has unexplained infertility? What what what what should we do? I don't know if that will be the answer that we're looking for today. But that's what we're probably looking to strive for. And, and that's literally just copy and pasting an Excel sheet. Imagine once you get these API's start working with these companies, and you really integrate with them to provide this type of data. I think it's, I think it's also like people, it freaks people out. But I think that when literally, when the calculator was invented, people thought, no one is going to know how to do math, we're all going to be stupid, nobody is going to use their brain anymore. And they're just going to rely on this device. And here we are today doing way, way more amazing things and advancing technology. And the calculator is a tool that you just use, and honestly half of us have moved away from that to things that are on our computer now.





Griffin Jones  54:15

Okay, so we can spend the next 10 to 15 minutes concluding this topic with going down these rabbit holes, because this is going to be fun, what you just brought up Ravi, the example of the calculator, how it's going to make people dumb, and people aren't going to know how to math do math anymore. Ravi, that did happen for probably 80% of the population. They can't do math anymore. And May and 20% can do math into levels of application that we had never even anticipated before. And probably a square root of that number is, you know, has just magnified the Einsteins of the world. But isn't that number getting smaller and smaller and smaller. smaller and the, the applications are greater and greater and greater. But eventually doesn't that number just become nil, because there's nothing that a human being can do to add value to collective general artificial intelligence,





55:17

definitely the edge of what we're talking about, I think Robbie talks about, like these alternative purposes for humans, and basically, what's going to create our, you know, Will and an ability to keep driving forward and stuff like that. And I do think that that those things will happen. But I do think there's a lot of fear around just that, which is, hey, listen, does the population as a whole get less intelligent? Or does a proportion of the population become less intelligent, and then you have this, you know, small niche of the population that continues down the road of research, and basically innovation and stuff like that. And that, you know, that's entirely the storyline of that time machine movie. So so i think i digress to the point





Dr. Ravi Gada  56:02

where it is, right. I mean, people have, maybe, maybe people have become worse at math worse at spelling, because Microsoft Word and everything auto corrects your spelling. And the older generations, like, gosh, we knew how to do all this, I feel like that sometimes. But the newer generation says, Well, you might know how to do math, and you might know how to spell. But these influencers are able to create a whole new, you know, industry, and they're able to create content, videos, edit it with through a computer that does it all with them. And it would take me eons of time to do that. And they can do that in a matter of an hour. And it would take me days, and I still might not get it right. So I might know what you know, the square root of 256 is and they're like, well, that doesn't matter. I've got a computer to help me do that. But you can't use the computer the way I can. So smartness is dependent on the tools that we have, I think that it, it forces people to be resourceful, and be able to use the tools you have. So just like you use a calculator, just like you use Microsoft Word, you're gonna have to learn how to use AI, and whether it's chatting GPT, or some other platform. And someone else might say, well, I could have written a beaut, I can write a beautiful act or essay on my own. Well, that's great. But if someone else can use a tool to do it 10 times faster and 10 times cheaper, they're probably going to win the race.





57:32

And we've seen this from a software point of view, we've seen this over the last, however, long, 40 years or so, right? Where software is now becoming easier and easier to produce, even what developers can accomplish in just a day versus what we had to do to do you know, back 20 years ago, just to get the same type of thing done has has totally changed. And so there's a rate limiter at some point in time where it's not going to matter that they can do more faster, because there's just not more to do. But we're not there yet, either. So, you know, our developers use chat GBT already today and just in the last few months, right? It helps them solve problems faster, it helps them optimize code that code faster, and a lot of things like that. But we have a long way to go before it replaces any of the developers. So





Dr. Ravi Gada  58:19

by the way, for for like normal people speak that like language model. This thing can code because code is a language so it can actually code software. And people are estimating 10 to 20% of software at at big companies is already being written by platforms like Chen GPT.





Griffin Jones  58:36

I see what you guys are saying human intelligence, resourcefulness, resilience, that's only one category of concern that I have. Let's pause it for a moment that we remain committed to innovation that we use this time, Robbie, like he says the possibility to be free to pursue other creative pursuits to enjoy life. Let's pause it for a moment that we don't actually get worse at anything. There still comes a point right? Where there is nothing that human intelligence and creativity can do to surpass that which a general artificial intelligence can think of let's let's think of ancient hominids, for example. It's some point they were equal at some point, humans parted with chimpanzees, and they parted ways with other previous hominids. But then not we live in a world where there is nothing that a chimpanzee can do to add value in a human being world other than be observed and be a pet. So doesn't that happen at some point? Where Yeah, no,





Dr. Ravi Gada  59:36

I mean, it's a great point. So what's interesting though, remember, AI and regenerative learning is data. Data input. So right now, someone estimated chat, GBT has 190 billion data inputs and it regurgitates it out. But it doesn't know what to put out unless it's been put in. So Chad GPT, for example, is likely or any AI is is likely not to figure out How to create this nuclear fusion between protons to generate energy, human intellect still is able to do that, right? They call it the neural network inside of AI. And what's in there is what's been inputted by humans. So a lot of people are saying that what's inside of the datasets, there'll be able to, you know, AI will be able to find it faster, regurgitate it, remodel it continue to do that. But it's always going to need to use or I say always, I should say, as of today is it needs source data, it needs innovation. So innovation is still going to come from humans. And we're going to do that. And then we submit it into a platform such as AI, and go from there. But as of today, I don't know that anybody has any great use cases of AI solving a problem that humans needed to invent or get to, it's really regurgitating all the things we have. And it's just gathering it faster and spitting it out faster. Maybe one day, we'll be able to have, you know, its own neural network that actually generates new ideas, but new ideas are still created by humans and put into the computer software system.





1:01:12

So I do think that there's some places where we're getting there, right. And that has to do with the sheer sheer compute power, right? This ability for it to go after large, large sets of data, right, and basically go through every permutation, right? So it's a little bit different from what we would think about as like new ideas. It's not necessarily a new idea. It's just a, hey, we've gone through every permutation of possible outcomes. And that's how we get there. And so there's, there's this, you know, looming threat or looming kind of, you know, fear of the fact that hey, listen, there's not anything more that we can do that hasn't been done by AI. But I do think that's right now, it's science fiction, at some point in time, it probably will become reality. But hopefully, it will be past my time.





Griffin Jones  1:02:02

The operative phrase that Dr. Gaga was using was as of today, and I think it's okay, as of today. But even Manish can think of a couple of applications where it's starting. And so what about what how long is as of today lasts for? Is it 10 years? Maybe? Is it 100 years? Probably not? Is it 1000 years? Almost certainly not? Almost? Certainly not?





1:02:26

Yeah, in grip. The interesting thing about that is that it's not a conversation about RBIs at all right? No, it's, you know, it's a





Griffin Jones  1:02:33

human race. Yeah. But it's the relevance of the human race.





1:02:37

Yeah. But even before that just passed, are you guys it's, you know, a cure for fertility, right. It's basically, you know, what's the pursuit? What's the purpose for, you know, humans and its happiness, and, you know, procreation and all these other kinds of facets. And so yeah, we'll get to a cure to fertility probably sooner than unnecessary need for humans.





Griffin Jones  1:03:02

I actually think it's going to be the thing that puts us all out of business, because I think it could even it could happen before a cure for fertility. I've said this for years that my long ball sci fi outcome is that,





1:03:16

but it'll be sustaining, right? It's putting us all out of jobs in order to sustain us otherwise, even the AI has no purpose without humans, but





Dr. Ravi Gada  1:03:25

it puts us out of business for what like we all are doing things so that we can be productive and earn money and then use that and enjoy life and have a purpose. But purpose will be redefined as it just as it was 100 years ago, where it is today. And it will be redefined again and another 100 years.





Griffin Jones  1:03:44

So I actually think it puts us out of the business of production. I mean, the the intersection of artificial intelligence and of virtual reality, I think that's what ultimately puts us out of, of the business of human production. Because when we can live in a world where we can augment our intelligence with artificial intelligence, so human beings are already cyborgs. This these devices that we carry around on us help to us to augment our intelligence and our communication abilities and all of our memory and then once that becomes further integrated with our brains with our nervous systems, and there's a virtual world in which we're able to participate, then eventually, what do you even need to reproduce physically in this physical world for you can have your augmented intelligence baby in your augmented reality world that never has to worry about dying that never has to worry about sickness that doesn't have to worry about human suffering. And I'm not saying this to you guys are smiling. Most people are going to be listening to this episode and not watching it so they can't see you smiling right now. I'm not saying this to be dystopian. I think this is just what's actually going to happen.





Dr. Ravi Gada  1:05:00

about maybe it puts us out of the business of being productive production, but it actually puts us back into the business of relationships and, and, and leisure and lifestyle.





1:05:10

And, and just to just to touch a little bit on the philosophical side of this, right, is just keep in mind the lifespan of a human is part of evolution. So,





Dr. Ravi Gada  1:05:24

that was pretty deep. I don't even know what that means.





Griffin Jones  1:05:26

Yeah, explain that many.





1:05:29

Yeah, so just kind of getting to the point that like, humans live the span of life that they live as a part of how we've evolved to become where we are right now, there's plenty of animals that live many, many years longer than humans and plenty of animals that live much shorter years than humans. And so, you know, that's, that's part of the equation as well. And, and the second thing that's kind of goes into that is it like, listen, we might have purpose with AI, but AI has no purpose without humans, either. Because what does a bunch of bots running around, servicing themselves and doing things for themselves me, either, that's a, that's a purposeless kind of function in that vein as well,





Griffin Jones  1:06:13

maybe, but I'm not convinced of that, they may find a purpose because the purpose of any living organism is just to continue existing. And human beings might be the first one to evolve itself out of existence. You talked about our relationship to other species in terms of how long we've been aren't, we haven't been around very long. It's been 200,000 years, I think, since humans separated from the last hominids. And when you look at our, our growth, it's been it's, it's a hockey stick, compared to the first years of leaving the canopy. And now civilization just in the past couple 1000 years, industrialization 200 years ago. And so I don't think this stuff is too far away. And I'm not trying to be dystopian, I just, I just don't think that I don't think there's any way for us to be able to contain it and control it. And so far you guys ever given otherwise?





Dr. Ravi Gada  1:07:09

You know, I think that people thought that when assembly lines came about, I think that they thought that when tractors came along, I think that is always been a worry. And it will always continue to be a worry. But ultimately, in a philosophical sense, humans are resilient. And like I said, we seem to stay ahead of the technology that we create ourselves. You know, at what point do we are we not able to stay ahead of it? Well, up until today, we still have I mean, people thought the world was over when assembly lines came in, and manufacturing jobs just got crushed, and what are we going to do and farming got replaced by equipment. And here we are today, three times the population with you know, 2% 3% unemployment, I mean, people are still employed doing something?





Griffin Jones  1:07:56

Well, if they said that, in the 1860s, as folks, were moving from steam to coal, you know, the late 1860s, or somewhere before the early 1880s. Whenever that happened, if they said, This is the end of humanity in the in the next five years, yeah, they would have been wrong. I think it's the amount of time where people get things wrong. I don't know if this is going to happen in a century or in a, or in an eon or a millennia. But I think it's inevitable that it will,





1:08:31

from that point of view, right? There's a this is not a country point, right? This is, you know, a we're never going to know, or we're not going to know, anytime soon. But in addition to that, yeah, I mean, it's definitely a possibility. And we'll have to figure out something else to do or something else to be or some other purpose to have, at that point in time. But, you know, it's, it's a tricky question, and probably well beyond our scope. So





Griffin Jones  1:08:59

it makes the premise of matrix a lot more interesting, doesn't it? You will never know except, and then and then what will happen? Well, if if you could, if you could evolve yourself out of existence, and then the only thing you had left to do was to recreate a previous existence? What period would you go back to accept the end of the 20th century? And it makes the promise even better,





Dr. Ravi Gada  1:09:22

right, right. Now, I've thought about the matrix A lot, you know, in looking and hearing about AI and its evolution, and it really makes that movie a lot more relevant.





1:09:31

Yeah. My only claim is I don't think they'll need us for batteries. So.





Griffin Jones  1:09:35

So you guys are optimistic. And I know that I might sound pessimistic, I don't think I'm being passed out. And I'm not making a value judgment. If all of this thing is is good, bad or neutral, but I want you guys to think a little bit about second and third order consequences. So Did either of you watch any of the interviews that Brett Weinstein has done about chat? GPT I bet but most of my audience doesn't know who Brett Weinstein is though. Those of you that do, I bet it's half and half about half the like, really critical thinkers really like him. And then other people might not like him because he's like the guy in the movie that is worried about everything. And he's always trying to warn about the media coming. And he's, he's, you know, he's worried about civil war. He's, he's very worried about the entire scientific and medical apparatus and feels that vaccines were rushed in that, you know, that that system was compromised, even if the vaccines themselves are safe, he feels that the the system was co opted. And one of the things that he's worried about is chat GPT given our fragile social relations right now and human beings, general incompetence to assess expertise already, you know, your peers, Ravi are very What are your peers often complained about is Dr. Google? And so if Dr. Google is them, though, and it's a avatar of them pulling from collective data points and, and its expertise that may or may not be scientifically grounded, then what are some second and third world? I'm sorry, second, or third order consequences that you might be concerned about?





Dr. Ravi Gada  1:11:15

Here? I mean, Brett Weinstein, he goes into things like it's able to pass exams, it's able to actually change GBT our licensing exam, as physicians is called the USMLE. It has passed both of those exams. And so if it's able to pass those exams, and people can access it on the internet very quickly, how do we discern who really knows? And who's just using chat GPT to present the answer? And I mean, there's two facets, I think, to that. dilemma. One is, you know, we all have been in oral exams, we've all taken exams in classrooms. I mean, the tool is only as good as you can access a computer and internet and be able to ask it those questions. But there's still a way to assess in education, because his big issue is education, and how people are using it to write essays and pass tests and do these things. Well, we've moved to a virtual education model post COVID. And maybe this brings us back into the universities, doing oral exams. I mean, you know, we've all been there. And and, and you can assess that in real time, you can assess an essay when you have Chad GPT able to write an essay for you, and how do you discern who's a good student and who's not. But again, in person education, we'll do some of that. The second part is, we already have things like chat GPT. Today, as physicians, we have up to date that we use as a resource. I have my partners, I have my colleagues, if I have a case that I'm not sure about, I pick up the phone, I talked to somebody, I get some information. I mean, it's a resource to augment and help our ability, but I think he does a lot of fear mongering, I think he likes to just the world is ending and everything. And that's okay, itself. But ultimately, there are ways in the education system to figure out who knows the right answer, and who doesn't, without having them taste, take tests at home. In the real world. You know, he gave an example, I think, at one point, have an auto mechanic and you just go in the auto mechanic asked Chad GPT. And he just sounds really smart. But how do you really know he knows, versus an auto mechanic who's been around for 20 years? And at





1:13:26

what point in time? Does that matter? Right? If I can get to the right answer, either way, right? It doesn't matter if the auto mechanic use chat UVT or not.





Dr. Ravi Gada  1:13:34

I mean, sometimes when I see someone come to the house for work, or you know, we're interviewing someone, one person might be really old school and has 20 years of historical knowledge. And the other one's a whippersnapper who uses all the resources around them to get to the answer. Which one do you want? I don't know. But that, you know, that depends on you know, what you're looking for?





Griffin Jones  1:13:53

Well, you talked about the assembly line, the farmers, you know, how those jobs have gone away, and how a lot of wealth was created by better jobs. And it really depended you. You all live in Texas, where you have a low regulation, low tech state that saw a lot of growth, but I live in a part of the country where many cities were decimated because they didn't adapt. And so you see different types of trajectories, I guess we would have to have a whole other conversation beyond our pay grade of what is the equitable distribution of, of benefits after chat GPT How do you even materially divide the spoils? And is that something that's possible to so that everybody can enjoy life as opposed to some of the people being able to enjoy life more from chat? GPT Are either of you guys? truckies





1:14:47

when I was a kid, I watched the soundtrack all the time. Yeah, the original





Griffin Jones  1:14:50

are next generation, next generation eyes. So next generation all the way what I'm hoping for is the holodeck. If we can all get the holodeck out of this you Then I think that's where the where the trade off. This has been the closest to any kind of Rogan episode I've ever done with you this is we're recording at almost 1130 at night on the East Coast. And I really could talk to you guys for three and a half hours about this. But we'll save that for another time because people are gonna listen to this, they're gonna Monday morning quarterback me just like Dr. Gowda doesn't say you should have asked them this you should have. And so I'll compile that I'll and I'll happily have you guys back on for a second time because this has been a blast. We've talked about the applications for the REI practice and for fertility patients. But we've also talked about the potential implications for the human race because you can't possibly contain this topic to just the REI practice, even when you're focusing on the applications for our field. It just goes so far beyond that. So how would you both like to conclude?





Dr. Ravi Gada  1:15:57

No, I mean, thanks for having us. Griff. You know, I know we've talked about coming on this before. But this was finally a topic that I feel very passionate about. I think that healthcare in general should embrace this. And I think that health care at a high level, will we as people in the side, the fertility industry have to figure out how do we take the data that we have, and not just data inside of the EMR, but all kinds of data to make sure we keep up and so we are working on this, you know, continuously, I think that others will join in and it will make us better, it will make our patients better, it will make outcomes better. So I'm not worried about the technology of the consequences of what does it do to jobs or do to us, but more how much it's going to improve our efficiencies and our outcomes. So those are the things that I think that technology helps. And technology is deflationary by nature. And maybe this also helps bring down the cost of IVF, which could help us be able to access more of the patients that are out there seeking care. So that's how I would, I would leave it.





1:17:04

And just that on the roof. Absolutely. This is a fun topic. You know, it's one of the ones that I think, you know, I can talk about tech all day long. This is one that, you know, definitely over the last few months has definitely been top of mine. Something that's just interesting has so many implications in fertility as well as far beyond, you know, any of your users that listen to this, if they haven't had a chance to even just log in, and just play around with. I mean, it's a different feeling right? To read an article about it versus actually start asking your questions and see what you'll understand a little bit why we're so excited about it. But appreciate you bringing us on the show. This is a lot of fun,





Griffin Jones  1:17:45

Manish Chaddua,  Dr. Ravi, Gada thank you both so much for coming on the inside reproductive health podcast. I look forward to having you back already.





Sponsor  1:17:54

This episode is brought to you by Univfy, email Dr. Yao at mylene.yao@univfy.com or just click on the button in this podcast, email, or web page for your free IVF artificial intelligence tips and strategies.  

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You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health