Matt Kraemer – Should Your ASC Accept Every Case? | This Week in Surgery Centers
Here’s what to expect on this week’s episode. 🎙️
Should your surgery center accept every case that it can? Or should you be more selective?
Matt Kraemer PT, DPT, FACHE is the Administrator of Northern Arizona Healthcare’s Orthopedic & Spine Institute. We sat down to chat about scenarios where it might be in your surgery center’s best interest to say no to certain cases.
Surgery centers are built to be highly efficient and to support high case volume. But many times, the profit margin on a case is much less than it would be at a hospital, so here are a few factors to consider before performing a surgery:
• Patient stability and safety
• Medical equipment and supplies
• Staff training & skillset
• Payer reimbursement
Matt’s surgery center evaluates each case to ensure every stakeholder is on board and to ensure it’s in the facility’s best interest to proceed. Here are the episode highlights:
• All cases need to be evaluated individually. You might accept a case 9 times out of 10, but that 10th time, it might not make sense.
• Sit down and have honest, data-driven conversations with your providers. Share with them exactly why proceeding with a specific case is not the best path forward.
• You will start to see incremental cost savings quarter over quarter. So far, Matt’s team has seen roughly a 60% improvement in their financial performance.
Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details.
Episode Transcript
0:00
welcome to this week in surgery centers if you’re in the ASC industry then
0:06
you’re in the right place every week we’ll start the episode off by sharing an interesting conversation we had with
0:11
our featured guests and then we’ll close the episode by recapping the latest news impacting surgery centers we’re excited
0:18
to share with you what we have so let’s get started and see what the industry’s been up to [Music]
0:28
hi everyone here’s what you can expect on today’s episode Matt Kramer is the
0:33
administrator of Northern Arizona Health Care Surgery Center and we sat down with him to chat about case acceptance and
0:41
we’re talking through the sometimes difficult question should you accept every case there are two scenarios where Matt’s
0:48
team will not accept a case and it boils down to patient safety or Revenue so
0:53
he’s sharing why this is important their approach to coming up with that decision and the results that they’ve seen so far
1:01
in our news recap we’ll cover a study that compared chat gpt’s responses
1:06
against physician responses the importance of discussing Transportation with every patient
1:12
what will uh disrupt the ASC industry next and of course and the new segment
1:18
with a positive story about a NICU nurse who adopted a teen and her triplets
1:23
and one final reminder if you are going to be at the ASCA conference in Louisville from May 17th to the 20th
1:30
make sure you stop by HST Pathways Booth to say hello I would love to see you all
1:35
during Exhibit Hall hours I’ll be holding very quick interviews with people right in the booth and we’re
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going to compile all the great responses we get and use it for an upcoming episode that will Air in late May so if
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you want to share your expertise with our listeners or just come by to say hi we only need a few minutes of your time
1:55
so come find us at HSC Pathways at Booth 519 and we’ll have a big Booth right in
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the middle of the floor you can’t miss it I hope everyone enjoys the episode and here’s what’s going on this week in
2:08
surgery centers Matt welcome to the show
2:14
yeah thanks for having me glad to be here Matt can you give us a quick overview of
2:19
your background in the ASC industry absolutely um so I’m an administrator for Northern
2:25
Arizona health care and um specifically over the orthopedic and Spine Institute which is a comprehensive Institute uh
2:32
involving employed providers as well as surgical operations including Ambulatory
2:38
Surgery Center that we have within our organization and I’ve been doing that for the last four years prior to that I
2:45
was also in healthcare as a physical therapist in multiple settings and a
2:51
healthcare administrator with other hcos in Arizona fantastic
2:56
and I want to talk to you today a little bit about case Acceptance in an ASC
3:02
environment because surgery centers aren’t hospitals it’s a different business model and it’s
3:09
more and more case volume gets shifted to outpatient facilities you know I think that that ASCS are
3:15
going to need to start paying more attention to case acceptance aren’t they absolutely yeah
3:22
and and Matt what’s your what’s your point of view bid on case acceptance how do you how do you think about that at
3:27
your current facility yeah I mean that’s a it’s a tricky situation to kind of manage
3:33
um obviously um Ambulatory Surgery centers are built highly on efficiencies and volume and
3:40
throughput um you know as well as a you know a great experience for not just the provider performing the surgeries but
3:46
for the the patients themselves and their recovery so we’re trying to execute on those fronts at the same time
3:54
many times those margins are are much less than what they would be in a hospital-based facility
4:01
um with a you know with an ASE fee schedule versus an hopdf schedule that also comes into play so how do you um
4:08
you know try to achieve the best outcomes for your patients and for your providers provide the throughput but
4:15
then also continue to manage a positive margin from a financial perspective
4:20
um you know and then you know be able to select or um you know accept those cases to keep
4:26
those providers happy and wanting to bring those cases to your facility right so you know
4:33
procedure margin it’s balancing the procedure margin with with the patient outcomes
4:38
how do you balance those two things what’s been your approach to evaluating cases
4:45
yeah it’s um it’s definitely not a you know a straightforward or an easy approach
4:50
um all the different variables that are in play are things that we have to take into consideration um patient stability
4:56
um that the type of case being performed uh medical equipment or medical supplies required to be able to form those cases
5:03
um staff staff training some of those cases require additional training um or specialization for um you know
5:10
safe case completion and then ultimately reimbursement you know um those those
5:16
payers that are that are supplying the the compensation to the facility um you know in order to be able to
5:22
perform those cases for their their covered lives um you know have variances in whether or
5:27
not they’re a government payer or whether they’re a commercial payer and contractually what they’re obligated to perform or provide
5:34
um and then what they actually authorized to provide as well so it’s it’s a matter of trying to to navigate
5:41
all those those various variables in that one equation which is that one patient case and determine whether or
5:49
not it’s something we can safely achieve as a comprehensive team and then still
5:54
manage to keep the lights on yeah that makes sense and you you mentioned a
6:02
lot of inputs that go into the case whether there’s any supplies and that’s reimbursement rates and stuff I want one
6:08
of the things we hear a good amount talking to our customers is especially in the Orthopedics World hey we don’t
6:15
always know all of our supply costs especially on the implant side going in and sometimes
6:20
we find out after the fact based on implants or supplies that were used a basically a case could have less margin
6:27
or even be you know non-profitable and kind of finding that after the fact how how at your facility how well do you
6:35
feel like you’ve got a good understanding of what supplies go into the case and what’s your what’s the cost
6:42
of that case going to be you know um I think we’re we’re getting better we’re
6:47
not where we want to be by any means um I think it’s a continual Journey um which you know most performance or
6:53
process Improvement is um you know I’ll say two years ago it wasn’t occurring on a at least on a
7:00
regular a regular basis and the information we had was I would State maybe 80 accurate
7:06
um you know nowadays I believe the systems that we have in place the individuals that we have
7:11
um contributing to performing those analyzes um you know are much much tighter um you
7:17
know 90 95 accurate um and we’ve built a bit of a database in identifying exactly all those
7:25
measures you were just referencing so you know how much staff do we need what is the cost of our staff our anesthesia
7:32
um the just the overhead the fixed cost associated with running the facility and
7:37
how that contributes to your overall volume and then also those variable costs so having implants having
7:43
capitated contracts with those vendors to ensure that in this facility it’s an implant we can’t afford to um to utilize
7:52
um and then the time that it takes to perform that case because you mentioned a couple things there you know and we’ve
7:59
both talked about it thus far you know supply cost and your and your labor
8:04
um you know or your um your employees are your greatest areas of of overhead
8:10
um and so how do you best you leverage or you know those resources
8:16
um you know or minimize the the cost as it pertains to the supply
8:21
um but then how do you leverage that resource of your salary and your benefits of all your your employees and
8:27
so that comes down to case consolidation or block utilization turnover times a
8:32
lot of the metrics that most the people that’ll view this are very familiar with um but really creating a bit of a
8:39
database as far as by case type by provider um and even by payer Source on whether
8:46
or not this is going to be uh either a tight margin um a positive margin or even you know
8:52
sometimes a negative margin um in which case we’re making we may consider continuing to perform that case
8:59
um just depending on the necessity of being of you know is it something that’s emergent
9:04
um is it truly the best place to perform that case for that patient um provider preference those types of
9:10
things um still come into play so it’s even with all that information it’s never really just a black and white
9:16
unfortunately sure but it does sound like with your database you’ve got it more dialed in than some and you’ve got
9:22
a kind of a good data set around it do you typically make decisions on if you
9:28
are going to not accept the case is that typically kind of a a case-by-case evaluation or is it more
9:35
hey by case type or the intersection of case type and pay yours you know maybe
9:40
there’s some on The Matrix that aren’t a good fit and some some that are how do you think about that yeah I mean I would
9:47
say um between those two options is definitely more of a case-by-case assessment um you know we’ll never just say hey
9:53
it’s just because it’s a you know whatever type of case um we’ll say a hip scope case
9:59
um with this type of payer or this type of implant or anchor system that we’re we’re you know a hard yes or a hard no
10:07
on that case we still will go through the analysis um you know by Provider by Time by
10:13
necessity emergency all those other factors that I’ve mentioned to determine you know nine times out of ten we might
10:20
we might accept this case but that there’s one time we might not um you know and so we’ll we’ll never
10:26
just be absolute across the board okay so it sounds like there’s a decent amount of kind of effort and time on the
10:32
front end to evaluate these cases yes a lot of rigor in in by all means it’s no
10:38
one individual you know for instance myself as the administrator I don’t I don’t make the call
10:43
um I rely on the on the consensus of the team we’ve got um you know a lot of people behind the scenes you know with our authorization
10:50
verification departments um rrn clinical manager overseeing you
10:55
know the the operations of the center itself um you know their team of charges are
11:01
our lead anesthesiologists our medical our physician medical director over the the facilities everybody’s coming
11:07
together to um you know perform this analysis and then provide their their recommendation
11:12
on how to move forward or not okay you mentioned safety earlier Matt
11:18
and how that can factor into case acceptance too how does that come into
11:24
your evaluation processes you know the ability to do a case safely yeah I mean that’s got to be first and
11:31
foremost um you know if you’re not performing safe cases uh you’re not going to be in business very long um forget the
11:37
finances of it forget you know how shiny or great your technology or your building might be
11:43
um if you’re having poor outcomes or um you know unsafe practices it’s only a matter of time before you’re no longer
11:49
operating so that’s got to be first and foremost um you know we’ve we’ve had situations where we’ve had to unfortunately refer
11:56
right in my case I believe fortunately refer a case um defert from our our facility over to
12:02
the main hospital because the case is 100 appropriate to be performed in an
12:07
Ambulatory Surgery Center by procedural type by provider everything in place
12:14
even by ASA scores which is you know one of our anesthesia measures of safety
12:19
however in deeper review um comprehensive review of that patient’s history we find some you know
12:26
anomalies that have us considered or I’m sorry have us concerned regarding how
12:31
that patient might potentially have difficulty with their recovery post anesthesia in the pacu
12:38
whether it be phase one or phase two and you know is that a longer length of stay is it a potential transfer to a higher
12:44
level of care do we believe that they’re they’re not going to be able to return to a normal vitals level in the
12:52
time that we have in order to achieve that and so um we might have to defer that case over the main hospital where
12:57
we know that that patient can spend a longer period of time in the pacu um you know even be potentially
13:04
transferred into an observation bed overnight so they can safely discharge home the next morning where we don’t
13:11
necessarily have that luxury in the in the surgery center got it okay
13:16
um so that’s helpful really helpful in terms of the overall framing of how you think about the case acceptance across
13:23
those two areas in terms of giving our listeners some specific examples maybe to bring it to
13:30
light a little bit can you share an example on the safety side of maybe a
13:36
case that you guys evaluated and said hey this this doesn’t feel right for us sure yeah I mean that that case actually
13:42
that I just referenced was an actual case where we had a a very appropriate
13:47
um patient coming in for um and I believe it was a a shoulder injury
13:53
um you know maybe a rotator cuff it was something very um you know typical of an Ambulatory Surgery Center in in Orthopedics for
14:00
that matter but unfortunately some of these other comorbidities or past medical history complications
14:07
um you know had us re-assess or reevaluate the appropriateness of this
14:12
patient um due to some of their respiratory based comp you know complex complexities
14:19
or complications um that we we deferred that case over to
14:24
the main or um you know where you don’t typically see a rotator cuff
14:29
um you know repair performed but as a result of this patient having um you know some perceived difficulties
14:36
with their ability to recover post anesthesia we felt it was just the safer call for them sure and same question for
14:43
you on the financial margin side can you give an example of when you evaluated a case and said hey from a margin
14:49
perspective this doesn’t seem like you know a good one for us to take on yeah
14:55
um very similarly Orthopedic case um ACL allograft case and um you know was
15:03
scheduled and no pair issues no past medical history um you know complexities
15:09
um that would kind of cloud our ability to accept the case but in speaking with the provider and then looking at their
15:16
medical supply requests um identifying that they were actually looking for two two graphs for this
15:22
patient versus one and then when we looked at that uh that particular case and had the conversation with the
15:29
Performing surgeon you know they mentioned that this was in this particular instance the best
15:34
um best practice for this patient was going to be to use two different graphs and combine those graphs into this
15:40
repair um you know and our approach was to educate the provider on how this was not
15:48
um a financially sustainable model for us um given the amount of reimbursement that we would receive for this case the
15:55
amount of Supply um in the tissue itself but then also in a longer case time
16:01
um the the labor to support that um you know we showed this this particular provider how it was going to
16:07
be a significant loss on this particular case and if they wish to use this type of approach for this patient and they
16:14
truly believe that this was the the only way to manage this particular patient
16:19
um that we were going to defer this case and they would need to perform this case in the main or at the hospital and this
16:26
provider essentially said well you know um I could probably come around on this and um you know we can make do with this
16:33
one graft and we can have some you know further conversations after this case is performed I really believe the ASC is
16:39
the appropriate setting for this this patient so we’ll we’ll move forward with just one graft and you know and go ahead and complete
16:46
the case which was then a you know a financially viable option for us
16:52
um you know but I think it was it was an eye-opening experience for the provider they just I think they just had an under
16:58
um understanding that you know they were going to make we make loads of money on these cases so you’re sharing some of
17:05
them the margin information and the cost of doing business with them I think it was a little eye-opening and they
17:10
started to maybe reconsider some of their approaches with particular patients that’s right A lot of times the providers of the facilities
17:16
don’t necessarily have the information on the overall profitability as they’re
17:23
you know developing the list of materials right and so correct yeah yeah
17:29
sorry go ahead no I was going to say in fact um you know that’s that’s 100 correct I would say the majority of the
17:35
time um versus many times I would say probably 90 of the time the providers don’t know
17:41
um and of those you know of that 90 of the time um you know those providers almost 100
17:47
of the time want to know um so they want that access to information um they want to know if they’re the most
17:54
expensive provider you know performing this case type and um you know I I will
17:59
also say that orthopedic surgeons are very competitive uh human beings um and they’re always looking to excel
18:06
whether that’s outcome based or just to be you know one of the most affordable and so they want to be able to produce
18:12
an outcome that you know is excellent and um you know leads the league in in
18:18
quality but then also is also you know one of the you know most least or least
18:24
expensive options for their patients um or for their surgical you know Center Partners
18:29
um and so they they’re looking for access to that information exactly and and what’s interesting is
18:36
those two things aren’t necessarily mutually exclusive right the the safety side and and the cost side and so that’s
18:43
that’s what’s interesting correct you know and and we make strategic decisions sometimes to um to knowingly accept a
18:51
case that is going to be um you know a margin loss or a negative margin
18:56
um because it is the right thing to do it’s the right it’s the right um approach for the patient it’s the right
19:02
um safety or outcome um focused decision um knowing that it’s not across the
19:07
board um and potentially it’s you know it’s to help assist a a surgeon you know achieve
19:12
their um you know their targets or their goals as well yep and so you guys have been thinking about
19:18
this at your Center in a thoughtful way in terms of kind of the margin side of these cases
19:25
um has it have you seen the impact on the overall facility profitability yeah I mean it’s definitely not a um a
19:32
quick turnaround so to you know so to say so to speak um you know it’s it’s one of those
19:37
things where you get it right um more times than not and then you start to get it right even more uh and
19:43
more and so over time you see your profitability for particular case types
19:48
um or quarter over a quarter or year over year start to improve um we’ve seen a you know consistent 60
19:55
60 roughly improvement in our financial performance um you know again incrementally Case by
20:02
case type provided by provider um you know and then eventually quarter over quarter and year over year so
20:10
um you know getting ourselves into a position where we’ve um we’re starting to hardwire that model to then you know
20:18
ensure Financial sustainability long term that’s fantastic you start stacking up
20:24
some of those 50 60 quarter over quarter Improvement that that’s gonna really add up over time you know um it’s it’s the
20:31
little things of taking two teams um you know in two different ORS and being able to consolidate them into one
20:37
um you know improving you the efficiencies of your turnover times um you know saying yes to some of those
20:42
cases that um that are you know longer but then also being able to say no to some of
20:47
those cases um that you believe to be too long or too expensive
20:52
um you know to to perform or that potentially allow for Quality
20:58
um Quality indicators to not be met you know as far as transfers to a higher level of um care and things like that
21:04
um and they do they add up those those one-off decisions over time um start to create a trend
21:10
um and then they build a culture you know everybody’s involved everybody’s engaged um you know from the the front line
21:17
staff whether they’re in the or in the pre-op or pacu space um SPD space or we’re in the insurance
21:23
verification space everybody’s aware of what it is we’re trying to achieve and then we engage our our physician
21:29
Partners to um to come along with that Journey um and it makes all the difference in the world I love it final question for
21:36
you Matt and we do this every week with our guests what’s one thing our listeners can do this week to improve
21:42
their surgery centers you know just the easy thing to say is you know just start looking at these
21:48
things you know start digging into these um these details and start kind of Performing your own root cause analysis
21:54
um you know we started off by just starting to create a spreadsheet I mean it was one simple spreadsheet where we
21:59
started to look at case types by Provider by times
22:05
um the the cost of supplies used in those cases and then based on our general contract averages what we would
22:12
expect to see from a reimbursement perspective and then as we started to build that um that list out started to
22:19
notice some Trends you know and that might have been a trend by case or by a vendor or by a contracted payer or a
22:25
provider and then have some conversations around that you know um this case becomes viable where it might
22:31
not be viable today it might become viable if we’re able to reduce the case Time by 10 minutes and what are the
22:37
things that we’re doing as part of our pre-operative setup or our closing process or our room turnover time
22:44
in order to shave off 10 minutes and if you shave off 10 minutes and you save you know a hundred dollars or a thousand
22:51
dollars and all of a sudden a potential loss on a Case um is a gain and you now you can recruit
22:57
more and more of those cases not to mention the byproduct typically when you’re faster and more efficient is a
23:04
much happier surgeon um you know happier patient it’s less anesthesia it’s faster recoveries and
23:09
better outcomes so awesome well thanks so much for joining us today
23:14
Matt oh it was my pleasure I appreciate you guys having me on
23:19
[Music] as always it has been a busy week in
23:25
healthcare so let’s Jump Right In this next story I love so for an
23:30
industry that has been notoriously slow to adopt new technologies it certainly
23:36
has not been ignoring the latest which is uh AI or chat GPT we’re already
23:42
hearing tons of stories about Healthcare leaders using AI in multiple ways assisting with clinical note-taking it’s
23:49
being used to generate hypothetical patient questions for medical students to practice with last week we reported
23:56
that it’s being integrated into epics EHR next year and there are so many other examples
24:01
but most recently a new study found that chat GPT might actually be useful and
24:07
successful in providing high quality answers to Patient questions um specifically during a time uh right
24:15
now where doctors and nurses are incredibly busy so the research evaluated two sets of answers to Patient
24:22
um questions one set of answers was written by physicians and the other was written by chat GPT a panel of
24:30
healthcare professionals then reviewed all of the responses and actually determined that chat gpt’s answers were
24:36
significantly more detailed and empathetic and the panel preferred chat gpt’s response is 79 of the time
24:46
um so I think what’s interesting about this is that we’re not talking about accuracy
24:52
um obviously you know the physician’s responses were completely accurate there was actually only uh let’s see there’s
25:00
only a handful of the physician responses that were deemed unacceptable by the panel
25:05
um but the accuracy and you know experience is not coming into play here and I I but
25:13
I think the most interesting part to me is the empathy Factor um it feels wrong that an AI tool could
25:19
be deemed more empathetic than a human being but if you think about it it
25:24
really all comes down to time so the reality is that chat GPT doesn’t have a
25:30
jam-packed schedule like our providers do it isn’t suffering from burnout it isn’t thinking about their next case or
25:36
the fact that they’ve answered the same question you know 2 000 times in their career which is the reality for our our
25:43
physicians and our providers so it’s not that the doctors aren’t empathetic they just don’t have the time to express it
25:50
so you know thinking through this I think the workflow might be that you know the patient question comes in chat
25:56
chat GPT could do the heavy lifting and answering the patient question initially
26:02
but then the physician can review the response for accuracy and and have final sign off before the patient does receive
26:08
a response um so that way it’s being used as a supporting tool and it’s a huge Time Saver and we’re still not you
26:15
know losing that human element and we don’t have to be worried that we’re sharing something incorrect with the
26:20
patient foreign a new study reveals that patients
26:27
without reliable transportation Miss more Health Care appointments which makes it harder for them to manage
26:33
chronic diseases receive preventative care make it to surgery and manage any
26:39
other health care needs in general um so there’s an element of that that is
26:44
of course a little bit obvious right someone doesn’t have reliable transportation how could we expect them
26:50
to reliably show up for their appointments but it not only you know it
26:56
not only affects the health of the patients which is a whole important conversation but it also creates a
27:04
financial burden on Health Care Providers it’s actually estimated that missed medical appointments can cost the
27:10
industry as much as 150 billion dollars annually in the us alone
27:16
so what do we do about this um in response some healthcare providers
27:22
are beginning to offer or continuing to offer transportation services to patients so some are partnering with The
27:29
Usual Suspects like uber and Lyft to give significant significantly discounted rides other providers are
27:36
using Community Vans or buses or just you know offering reimbursements for the regular TAXI fares
27:42
um and obviously we want to make sure that everybody in our community is able
27:47
to make it to an appointment if they need it um obviously receiving receiving regular
27:53
care or even being able to follow up on your after surgery to your appointments will help avoid you know that 911 call
28:00
and the and the emergency visit um but I think the biggest takeaway from
28:06
this study is the importance of addressing Transportation as a social determinant of health and investing in
28:14
solutions to make sure that your patients have reliable access to get to you when they need to it’s all of our
28:21
responsibility within our communities to address this so specifically adults with
28:27
disabilities black adults people with low incomes and those on public Insurance are more likely to report
28:33
going without Health Care um because of Transportation issues so
28:39
it’s important to get ahead of any potential Transportation issues during the pre-assessment process if you are
28:46
interested in learning more about social determinants of Health more cash is the
28:51
VP of clinical strategies here at HSC Pathways and she will actually be speaking at ASCA in Louisville on
28:58
Thursday May 18th in the morning um she has one of the morning sessions and and
29:03
the topic is the ASC industry’s role in reducing the disparity of care and she will be covering this in detail so as I
29:11
said it’s really something that is the community’s responsibility to make sure all of our members are able to get to
29:18
their health care appointments their surgery appointments when they need to
29:24
in our third story Becker’s ASC asked four ASC leaders the same question what
29:31
will disrupt the ASC industry next now they all had really interesting responses we’ll include the link in the
29:37
episode show notes I highly recommend reading through all of them um you know they covered a lot of the usual
29:44
Trends consolidation team-based care delivery models supply chain and Staffing woes but I wanted to share in
29:52
detail the responses from Ragu ready he is the chief administrative officer of
29:58
surge Center of Western Maryland and he had five distinct disruptors that he
30:03
shared that I wanted to pass along that I thought were great the first is the
30:09
evolution of out of the hospital strategy for payers in CMS we’ve talked about this um a couple times now
30:16
specifically Cardiology is making significant inroads already
30:21
the second is technology is going to impact the ASC industry significantly with robotics Ai and 3D printing
30:30
the addition of more procedures to the ASC covered procedures list by CMS and
30:36
the rise of hybrid ASCS to adapt to the reimbursement shifts the fourth is private Equity firms will
30:44
dominate the mergers and Acquisitions market and hospitals will increase their focus on their ASC strategy
30:50
and the fifth is implementation of value-based care and stringent certificate of need law states will have
30:56
to adopt adapt to lower the health care costs so I thought those Five Points were nice and
31:02
succinct and he did an excellent job summarizing what’s to come and I agree
31:07
that it will be especially interesting to see what happens with the ASC CPL this year given the push we’re seeing
31:13
from inpatient to outpatient settings foreign and to end our new segment on a positive
31:20
note Katrina Mullen is a NICU nurse from Cleveland Ohio and she has adopted a
31:26
Teen Mom in her newborn triplets the nurse developed a strong bond with the
31:31
teen when the baby was in her care the teen had been in foster care and didn’t really have a stable home environment
31:37
which inspired Mullen to adopt her and provide her with a safe and loving home the adoption was finalized in January
31:45
2021 and the family is now thriving together so she adopted the mom and her
31:51
three babies which is such a beautiful story I’m so glad that they all got to stay together
31:57
um and you know I especially love this story because it really highlights a special relationship that can form
32:02
between a nurse a health care provider and the patient and really the impact that they can have on each other’s lives
32:09
and that news story officially wraps up this week’s podcast thank you as always
32:15
for spending a few minutes of your week with us make sure to subscribe or leave a review on whichever platform you’re
32:21
listening from I hope you have a great day and we will see you again next week
32:28
[Music] why are you keeping me
welcome to this week in surgery centers if you’re in the ASC industry then
0:06
you’re in the right place every week we’ll start the episode off by sharing an interesting conversation we had with
0:11
our featured guests and then we’ll close the episode by recapping the latest news impacting surgery centers we’re excited
0:18
to share with you what we have so let’s get started and see what the industry’s been up to [Music]
0:28
hi everyone here’s what you can expect on today’s episode Matt Kramer is the
0:33
administrator of Northern Arizona Health Care Surgery Center and we sat down with him to chat about case acceptance and
0:41
we’re talking through the sometimes difficult question should you accept every case there are two scenarios where Matt’s
0:48
team will not accept a case and it boils down to patient safety or Revenue so
0:53
he’s sharing why this is important their approach to coming up with that decision and the results that they’ve seen so far
1:01
in our news recap we’ll cover a study that compared chat gpt’s responses
1:06
against physician responses the importance of discussing Transportation with every patient
1:12
what will uh disrupt the ASC industry next and of course and the new segment
1:18
with a positive story about a NICU nurse who adopted a teen and her triplets
1:23
and one final reminder if you are going to be at the ASCA conference in Louisville from May 17th to the 20th
1:30
make sure you stop by HST Pathways Booth to say hello I would love to see you all
1:35
during Exhibit Hall hours I’ll be holding very quick interviews with people right in the booth and we’re
1:42
going to compile all the great responses we get and use it for an upcoming episode that will Air in late May so if
1:49
you want to share your expertise with our listeners or just come by to say hi we only need a few minutes of your time
1:55
so come find us at HSC Pathways at Booth 519 and we’ll have a big Booth right in
2:01
the middle of the floor you can’t miss it I hope everyone enjoys the episode and here’s what’s going on this week in
2:08
surgery centers Matt welcome to the show
2:14
yeah thanks for having me glad to be here Matt can you give us a quick overview of
2:19
your background in the ASC industry absolutely um so I’m an administrator for Northern
2:25
Arizona health care and um specifically over the orthopedic and Spine Institute which is a comprehensive Institute uh
2:32
involving employed providers as well as surgical operations including Ambulatory
2:38
Surgery Center that we have within our organization and I’ve been doing that for the last four years prior to that I
2:45
was also in healthcare as a physical therapist in multiple settings and a
2:51
healthcare administrator with other hcos in Arizona fantastic
2:56
and I want to talk to you today a little bit about case Acceptance in an ASC
3:02
environment because surgery centers aren’t hospitals it’s a different business model and it’s
3:09
more and more case volume gets shifted to outpatient facilities you know I think that that ASCS are
3:15
going to need to start paying more attention to case acceptance aren’t they absolutely yeah
3:22
and and Matt what’s your what’s your point of view bid on case acceptance how do you how do you think about that at
3:27
your current facility yeah I mean that’s a it’s a tricky situation to kind of manage
3:33
um obviously um Ambulatory Surgery centers are built highly on efficiencies and volume and
3:40
throughput um you know as well as a you know a great experience for not just the provider performing the surgeries but
3:46
for the the patients themselves and their recovery so we’re trying to execute on those fronts at the same time
3:54
many times those margins are are much less than what they would be in a hospital-based facility
4:01
um with a you know with an ASE fee schedule versus an hopdf schedule that also comes into play so how do you um
4:08
you know try to achieve the best outcomes for your patients and for your providers provide the throughput but
4:15
then also continue to manage a positive margin from a financial perspective
4:20
um you know and then you know be able to select or um you know accept those cases to keep
4:26
those providers happy and wanting to bring those cases to your facility right so you know
4:33
procedure margin it’s balancing the procedure margin with with the patient outcomes
4:38
how do you balance those two things what’s been your approach to evaluating cases
4:45
yeah it’s um it’s definitely not a you know a straightforward or an easy approach
4:50
um all the different variables that are in play are things that we have to take into consideration um patient stability
4:56
um that the type of case being performed uh medical equipment or medical supplies required to be able to form those cases
5:03
um staff staff training some of those cases require additional training um or specialization for um you know
5:10
safe case completion and then ultimately reimbursement you know um those those
5:16
payers that are that are supplying the the compensation to the facility um you know in order to be able to
5:22
perform those cases for their their covered lives um you know have variances in whether or
5:27
not they’re a government payer or whether they’re a commercial payer and contractually what they’re obligated to perform or provide
5:34
um and then what they actually authorized to provide as well so it’s it’s a matter of trying to to navigate
5:41
all those those various variables in that one equation which is that one patient case and determine whether or
5:49
not it’s something we can safely achieve as a comprehensive team and then still
5:54
manage to keep the lights on yeah that makes sense and you you mentioned a
6:02
lot of inputs that go into the case whether there’s any supplies and that’s reimbursement rates and stuff I want one
6:08
of the things we hear a good amount talking to our customers is especially in the Orthopedics World hey we don’t
6:15
always know all of our supply costs especially on the implant side going in and sometimes
6:20
we find out after the fact based on implants or supplies that were used a basically a case could have less margin
6:27
or even be you know non-profitable and kind of finding that after the fact how how at your facility how well do you
6:35
feel like you’ve got a good understanding of what supplies go into the case and what’s your what’s the cost
6:42
of that case going to be you know um I think we’re we’re getting better we’re
6:47
not where we want to be by any means um I think it’s a continual Journey um which you know most performance or
6:53
process Improvement is um you know I’ll say two years ago it wasn’t occurring on a at least on a
7:00
regular a regular basis and the information we had was I would State maybe 80 accurate
7:06
um you know nowadays I believe the systems that we have in place the individuals that we have
7:11
um contributing to performing those analyzes um you know are much much tighter um you
7:17
know 90 95 accurate um and we’ve built a bit of a database in identifying exactly all those
7:25
measures you were just referencing so you know how much staff do we need what is the cost of our staff our anesthesia
7:32
um the just the overhead the fixed cost associated with running the facility and
7:37
how that contributes to your overall volume and then also those variable costs so having implants having
7:43
capitated contracts with those vendors to ensure that in this facility it’s an implant we can’t afford to um to utilize
7:52
um and then the time that it takes to perform that case because you mentioned a couple things there you know and we’ve
7:59
both talked about it thus far you know supply cost and your and your labor
8:04
um you know or your um your employees are your greatest areas of of overhead
8:10
um and so how do you best you leverage or you know those resources
8:16
um you know or minimize the the cost as it pertains to the supply
8:21
um but then how do you leverage that resource of your salary and your benefits of all your your employees and
8:27
so that comes down to case consolidation or block utilization turnover times a
8:32
lot of the metrics that most the people that’ll view this are very familiar with um but really creating a bit of a
8:39
database as far as by case type by provider um and even by payer Source on whether
8:46
or not this is going to be uh either a tight margin um a positive margin or even you know
8:52
sometimes a negative margin um in which case we’re making we may consider continuing to perform that case
8:59
um just depending on the necessity of being of you know is it something that’s emergent
9:04
um is it truly the best place to perform that case for that patient um provider preference those types of
9:10
things um still come into play so it’s even with all that information it’s never really just a black and white
9:16
unfortunately sure but it does sound like with your database you’ve got it more dialed in than some and you’ve got
9:22
a kind of a good data set around it do you typically make decisions on if you
9:28
are going to not accept the case is that typically kind of a a case-by-case evaluation or is it more
9:35
hey by case type or the intersection of case type and pay yours you know maybe
9:40
there’s some on The Matrix that aren’t a good fit and some some that are how do you think about that yeah I mean I would
9:47
say um between those two options is definitely more of a case-by-case assessment um you know we’ll never just say hey
9:53
it’s just because it’s a you know whatever type of case um we’ll say a hip scope case
9:59
um with this type of payer or this type of implant or anchor system that we’re we’re you know a hard yes or a hard no
10:07
on that case we still will go through the analysis um you know by Provider by Time by
10:13
necessity emergency all those other factors that I’ve mentioned to determine you know nine times out of ten we might
10:20
we might accept this case but that there’s one time we might not um you know and so we’ll we’ll never
10:26
just be absolute across the board okay so it sounds like there’s a decent amount of kind of effort and time on the
10:32
front end to evaluate these cases yes a lot of rigor in in by all means it’s no
10:38
one individual you know for instance myself as the administrator I don’t I don’t make the call
10:43
um I rely on the on the consensus of the team we’ve got um you know a lot of people behind the scenes you know with our authorization
10:50
verification departments um rrn clinical manager overseeing you
10:55
know the the operations of the center itself um you know their team of charges are
11:01
our lead anesthesiologists our medical our physician medical director over the the facilities everybody’s coming
11:07
together to um you know perform this analysis and then provide their their recommendation
11:12
on how to move forward or not okay you mentioned safety earlier Matt
11:18
and how that can factor into case acceptance too how does that come into
11:24
your evaluation processes you know the ability to do a case safely yeah I mean that’s got to be first and
11:31
foremost um you know if you’re not performing safe cases uh you’re not going to be in business very long um forget the
11:37
finances of it forget you know how shiny or great your technology or your building might be
11:43
um if you’re having poor outcomes or um you know unsafe practices it’s only a matter of time before you’re no longer
11:49
operating so that’s got to be first and foremost um you know we’ve we’ve had situations where we’ve had to unfortunately refer
11:56
right in my case I believe fortunately refer a case um defert from our our facility over to
12:02
the main hospital because the case is 100 appropriate to be performed in an
12:07
Ambulatory Surgery Center by procedural type by provider everything in place
12:14
even by ASA scores which is you know one of our anesthesia measures of safety
12:19
however in deeper review um comprehensive review of that patient’s history we find some you know
12:26
anomalies that have us considered or I’m sorry have us concerned regarding how
12:31
that patient might potentially have difficulty with their recovery post anesthesia in the pacu
12:38
whether it be phase one or phase two and you know is that a longer length of stay is it a potential transfer to a higher
12:44
level of care do we believe that they’re they’re not going to be able to return to a normal vitals level in the
12:52
time that we have in order to achieve that and so um we might have to defer that case over the main hospital where
12:57
we know that that patient can spend a longer period of time in the pacu um you know even be potentially
13:04
transferred into an observation bed overnight so they can safely discharge home the next morning where we don’t
13:11
necessarily have that luxury in the in the surgery center got it okay
13:16
um so that’s helpful really helpful in terms of the overall framing of how you think about the case acceptance across
13:23
those two areas in terms of giving our listeners some specific examples maybe to bring it to
13:30
light a little bit can you share an example on the safety side of maybe a
13:36
case that you guys evaluated and said hey this this doesn’t feel right for us sure yeah I mean that that case actually
13:42
that I just referenced was an actual case where we had a a very appropriate
13:47
um patient coming in for um and I believe it was a a shoulder injury
13:53
um you know maybe a rotator cuff it was something very um you know typical of an Ambulatory Surgery Center in in Orthopedics for
14:00
that matter but unfortunately some of these other comorbidities or past medical history complications
14:07
um you know had us re-assess or reevaluate the appropriateness of this
14:12
patient um due to some of their respiratory based comp you know complex complexities
14:19
or complications um that we we deferred that case over to
14:24
the main or um you know where you don’t typically see a rotator cuff
14:29
um you know repair performed but as a result of this patient having um you know some perceived difficulties
14:36
with their ability to recover post anesthesia we felt it was just the safer call for them sure and same question for
14:43
you on the financial margin side can you give an example of when you evaluated a case and said hey from a margin
14:49
perspective this doesn’t seem like you know a good one for us to take on yeah
14:55
um very similarly Orthopedic case um ACL allograft case and um you know was
15:03
scheduled and no pair issues no past medical history um you know complexities
15:09
um that would kind of cloud our ability to accept the case but in speaking with the provider and then looking at their
15:16
medical supply requests um identifying that they were actually looking for two two graphs for this
15:22
patient versus one and then when we looked at that uh that particular case and had the conversation with the
15:29
Performing surgeon you know they mentioned that this was in this particular instance the best
15:34
um best practice for this patient was going to be to use two different graphs and combine those graphs into this
15:40
repair um you know and our approach was to educate the provider on how this was not
15:48
um a financially sustainable model for us um given the amount of reimbursement that we would receive for this case the
15:55
amount of Supply um in the tissue itself but then also in a longer case time
16:01
um the the labor to support that um you know we showed this this particular provider how it was going to
16:07
be a significant loss on this particular case and if they wish to use this type of approach for this patient and they
16:14
truly believe that this was the the only way to manage this particular patient
16:19
um that we were going to defer this case and they would need to perform this case in the main or at the hospital and this
16:26
provider essentially said well you know um I could probably come around on this and um you know we can make do with this
16:33
one graft and we can have some you know further conversations after this case is performed I really believe the ASC is
16:39
the appropriate setting for this this patient so we’ll we’ll move forward with just one graft and you know and go ahead and complete
16:46
the case which was then a you know a financially viable option for us
16:52
um you know but I think it was it was an eye-opening experience for the provider they just I think they just had an under
16:58
um understanding that you know they were going to make we make loads of money on these cases so you’re sharing some of
17:05
them the margin information and the cost of doing business with them I think it was a little eye-opening and they
17:10
started to maybe reconsider some of their approaches with particular patients that’s right A lot of times the providers of the facilities
17:16
don’t necessarily have the information on the overall profitability as they’re
17:23
you know developing the list of materials right and so correct yeah yeah
17:29
sorry go ahead no I was going to say in fact um you know that’s that’s 100 correct I would say the majority of the
17:35
time um versus many times I would say probably 90 of the time the providers don’t know
17:41
um and of those you know of that 90 of the time um you know those providers almost 100
17:47
of the time want to know um so they want that access to information um they want to know if they’re the most
17:54
expensive provider you know performing this case type and um you know I I will
17:59
also say that orthopedic surgeons are very competitive uh human beings um and they’re always looking to excel
18:06
whether that’s outcome based or just to be you know one of the most affordable and so they want to be able to produce
18:12
an outcome that you know is excellent and um you know leads the league in in
18:18
quality but then also is also you know one of the you know most least or least
18:24
expensive options for their patients um or for their surgical you know Center Partners
18:29
um and so they they’re looking for access to that information exactly and and what’s interesting is
18:36
those two things aren’t necessarily mutually exclusive right the the safety side and and the cost side and so that’s
18:43
that’s what’s interesting correct you know and and we make strategic decisions sometimes to um to knowingly accept a
18:51
case that is going to be um you know a margin loss or a negative margin
18:56
um because it is the right thing to do it’s the right it’s the right um approach for the patient it’s the right
19:02
um safety or outcome um focused decision um knowing that it’s not across the
19:07
board um and potentially it’s you know it’s to help assist a a surgeon you know achieve
19:12
their um you know their targets or their goals as well yep and so you guys have been thinking about
19:18
this at your Center in a thoughtful way in terms of kind of the margin side of these cases
19:25
um has it have you seen the impact on the overall facility profitability yeah I mean it’s definitely not a um a
19:32
quick turnaround so to you know so to say so to speak um you know it’s it’s one of those
19:37
things where you get it right um more times than not and then you start to get it right even more uh and
19:43
more and so over time you see your profitability for particular case types
19:48
um or quarter over a quarter or year over year start to improve um we’ve seen a you know consistent 60
19:55
60 roughly improvement in our financial performance um you know again incrementally Case by
20:02
case type provided by provider um you know and then eventually quarter over quarter and year over year so
20:10
um you know getting ourselves into a position where we’ve um we’re starting to hardwire that model to then you know
20:18
ensure Financial sustainability long term that’s fantastic you start stacking up
20:24
some of those 50 60 quarter over quarter Improvement that that’s gonna really add up over time you know um it’s it’s the
20:31
little things of taking two teams um you know in two different ORS and being able to consolidate them into one
20:37
um you know improving you the efficiencies of your turnover times um you know saying yes to some of those
20:42
cases that um that are you know longer but then also being able to say no to some of
20:47
those cases um that you believe to be too long or too expensive
20:52
um you know to to perform or that potentially allow for Quality
20:58
um Quality indicators to not be met you know as far as transfers to a higher level of um care and things like that
21:04
um and they do they add up those those one-off decisions over time um start to create a trend
21:10
um and then they build a culture you know everybody’s involved everybody’s engaged um you know from the the front line
21:17
staff whether they’re in the or in the pre-op or pacu space um SPD space or we’re in the insurance
21:23
verification space everybody’s aware of what it is we’re trying to achieve and then we engage our our physician
21:29
Partners to um to come along with that Journey um and it makes all the difference in the world I love it final question for
21:36
you Matt and we do this every week with our guests what’s one thing our listeners can do this week to improve
21:42
their surgery centers you know just the easy thing to say is you know just start looking at these
21:48
things you know start digging into these um these details and start kind of Performing your own root cause analysis
21:54
um you know we started off by just starting to create a spreadsheet I mean it was one simple spreadsheet where we
21:59
started to look at case types by Provider by times
22:05
um the the cost of supplies used in those cases and then based on our general contract averages what we would
22:12
expect to see from a reimbursement perspective and then as we started to build that um that list out started to
22:19
notice some Trends you know and that might have been a trend by case or by a vendor or by a contracted payer or a
22:25
provider and then have some conversations around that you know um this case becomes viable where it might
22:31
not be viable today it might become viable if we’re able to reduce the case Time by 10 minutes and what are the
22:37
things that we’re doing as part of our pre-operative setup or our closing process or our room turnover time
22:44
in order to shave off 10 minutes and if you shave off 10 minutes and you save you know a hundred dollars or a thousand
22:51
dollars and all of a sudden a potential loss on a Case um is a gain and you now you can recruit
22:57
more and more of those cases not to mention the byproduct typically when you’re faster and more efficient is a
23:04
much happier surgeon um you know happier patient it’s less anesthesia it’s faster recoveries and
23:09
better outcomes so awesome well thanks so much for joining us today
23:14
Matt oh it was my pleasure I appreciate you guys having me on
23:19
[Music] as always it has been a busy week in
23:25
healthcare so let’s Jump Right In this next story I love so for an
23:30
industry that has been notoriously slow to adopt new technologies it certainly
23:36
has not been ignoring the latest which is uh AI or chat GPT we’re already
23:42
hearing tons of stories about Healthcare leaders using AI in multiple ways assisting with clinical note-taking it’s
23:49
being used to generate hypothetical patient questions for medical students to practice with last week we reported
23:56
that it’s being integrated into epics EHR next year and there are so many other examples
24:01
but most recently a new study found that chat GPT might actually be useful and
24:07
successful in providing high quality answers to Patient questions um specifically during a time uh right
24:15
now where doctors and nurses are incredibly busy so the research evaluated two sets of answers to Patient
24:22
um questions one set of answers was written by physicians and the other was written by chat GPT a panel of
24:30
healthcare professionals then reviewed all of the responses and actually determined that chat gpt’s answers were
24:36
significantly more detailed and empathetic and the panel preferred chat gpt’s response is 79 of the time
24:46
um so I think what’s interesting about this is that we’re not talking about accuracy
24:52
um obviously you know the physician’s responses were completely accurate there was actually only uh let’s see there’s
25:00
only a handful of the physician responses that were deemed unacceptable by the panel
25:05
um but the accuracy and you know experience is not coming into play here and I I but
25:13
I think the most interesting part to me is the empathy Factor um it feels wrong that an AI tool could
25:19
be deemed more empathetic than a human being but if you think about it it
25:24
really all comes down to time so the reality is that chat GPT doesn’t have a
25:30
jam-packed schedule like our providers do it isn’t suffering from burnout it isn’t thinking about their next case or
25:36
the fact that they’ve answered the same question you know 2 000 times in their career which is the reality for our our
25:43
physicians and our providers so it’s not that the doctors aren’t empathetic they just don’t have the time to express it
25:50
so you know thinking through this I think the workflow might be that you know the patient question comes in chat
25:56
chat GPT could do the heavy lifting and answering the patient question initially
26:02
but then the physician can review the response for accuracy and and have final sign off before the patient does receive
26:08
a response um so that way it’s being used as a supporting tool and it’s a huge Time Saver and we’re still not you
26:15
know losing that human element and we don’t have to be worried that we’re sharing something incorrect with the
26:20
patient foreign a new study reveals that patients
26:27
without reliable transportation Miss more Health Care appointments which makes it harder for them to manage
26:33
chronic diseases receive preventative care make it to surgery and manage any
26:39
other health care needs in general um so there’s an element of that that is
26:44
of course a little bit obvious right someone doesn’t have reliable transportation how could we expect them
26:50
to reliably show up for their appointments but it not only you know it
26:56
not only affects the health of the patients which is a whole important conversation but it also creates a
27:04
financial burden on Health Care Providers it’s actually estimated that missed medical appointments can cost the
27:10
industry as much as 150 billion dollars annually in the us alone
27:16
so what do we do about this um in response some healthcare providers
27:22
are beginning to offer or continuing to offer transportation services to patients so some are partnering with The
27:29
Usual Suspects like uber and Lyft to give significant significantly discounted rides other providers are
27:36
using Community Vans or buses or just you know offering reimbursements for the regular TAXI fares
27:42
um and obviously we want to make sure that everybody in our community is able
27:47
to make it to an appointment if they need it um obviously receiving receiving regular
27:53
care or even being able to follow up on your after surgery to your appointments will help avoid you know that 911 call
28:00
and the and the emergency visit um but I think the biggest takeaway from
28:06
this study is the importance of addressing Transportation as a social determinant of health and investing in
28:14
solutions to make sure that your patients have reliable access to get to you when they need to it’s all of our
28:21
responsibility within our communities to address this so specifically adults with
28:27
disabilities black adults people with low incomes and those on public Insurance are more likely to report
28:33
going without Health Care um because of Transportation issues so
28:39
it’s important to get ahead of any potential Transportation issues during the pre-assessment process if you are
28:46
interested in learning more about social determinants of Health more cash is the
28:51
VP of clinical strategies here at HSC Pathways and she will actually be speaking at ASCA in Louisville on
28:58
Thursday May 18th in the morning um she has one of the morning sessions and and
29:03
the topic is the ASC industry’s role in reducing the disparity of care and she will be covering this in detail so as I
29:11
said it’s really something that is the community’s responsibility to make sure all of our members are able to get to
29:18
their health care appointments their surgery appointments when they need to
29:24
in our third story Becker’s ASC asked four ASC leaders the same question what
29:31
will disrupt the ASC industry next now they all had really interesting responses we’ll include the link in the
29:37
episode show notes I highly recommend reading through all of them um you know they covered a lot of the usual
29:44
Trends consolidation team-based care delivery models supply chain and Staffing woes but I wanted to share in
29:52
detail the responses from Ragu ready he is the chief administrative officer of
29:58
surge Center of Western Maryland and he had five distinct disruptors that he
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shared that I wanted to pass along that I thought were great the first is the
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evolution of out of the hospital strategy for payers in CMS we’ve talked about this um a couple times now
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specifically Cardiology is making significant inroads already
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the second is technology is going to impact the ASC industry significantly with robotics Ai and 3D printing
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the addition of more procedures to the ASC covered procedures list by CMS and
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the rise of hybrid ASCS to adapt to the reimbursement shifts the fourth is private Equity firms will
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dominate the mergers and Acquisitions market and hospitals will increase their focus on their ASC strategy
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and the fifth is implementation of value-based care and stringent certificate of need law states will have
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to adopt adapt to lower the health care costs so I thought those Five Points were nice and
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succinct and he did an excellent job summarizing what’s to come and I agree
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that it will be especially interesting to see what happens with the ASC CPL this year given the push we’re seeing
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from inpatient to outpatient settings foreign and to end our new segment on a positive
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note Katrina Mullen is a NICU nurse from Cleveland Ohio and she has adopted a
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Teen Mom in her newborn triplets the nurse developed a strong bond with the
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teen when the baby was in her care the teen had been in foster care and didn’t really have a stable home environment
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which inspired Mullen to adopt her and provide her with a safe and loving home the adoption was finalized in January
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2021 and the family is now thriving together so she adopted the mom and her
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three babies which is such a beautiful story I’m so glad that they all got to stay together
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um and you know I especially love this story because it really highlights a special relationship that can form
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between a nurse a health care provider and the patient and really the impact that they can have on each other’s lives
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and that news story officially wraps up this week’s podcast thank you as always
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for spending a few minutes of your week with us make sure to subscribe or leave a review on whichever platform you’re
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listening from I hope you have a great day and we will see you again next week
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[Music] why are you keeping me
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