September 12, 2026 • 41 mins
Nobody warns you that medicine is also payroll, leases, audits and phones that never stop ringing. We sit down with Dr Mike Daniels, a podiatrist with an MBA and the president and CMO of WeTreatFeet, to talk about the business of being a doctor and what happens when clinical training collides with the realities of running an insurance-based healthcare practice in the US.
We get into the moment many clinicians face: you can look after patients brilliantly, but still feel lost when you have to hire and lead a team, manage cash flow, negotiate with payers, and survive declining reimbursement. Mike explains why overhead is so high in American healthcare, how the revenue cycle works from documentation and coding through claim scrubbing and clearinghouses, and why “just see more patients” eventually breaks both quality and capacity.
From there, we explore what it means to build an organisation rather than a single practice. Mike shares how service lines like durable medical equipment, diabetic shoes, wound supplies, compression garments, in-office procedures and clinical trials can improve patient compliance and satisfaction while diversifying revenue. We also talk expansion strategy: acquisition versus starting a new site, the churn that follows a practice purchase, and the internal resistance that comes with any operational change.
If you’re a clinician, practice owner, or healthcare leader thinking about sustainable growth, physician entrepreneurship, or an eventual exit strategy, this conversation offers a clear-eyed look at the trade-offs and the skills nobody teaches. Subscribe, share this with a colleague, and leave a review with your biggest question about the business side of medicine.
GUEST BIOGRAPHY
Dr. Mikel Daniels, DPM, MBA is a podiatrist, healthcare executive and President, CMO and Managing Member of WeTreatFeet Podiatry and WeTreatFeet MSO, LLC.
Over his career, Dr. Daniels has progressed from clinical practice and partnership into the development of a broader podiatric platform incorporating multiple offices and service lines. His experience spans patient care, practice operations, medical billing, healthcare administration, clinical trials and the financial realities of operating within the US insurance-based healthcare system.
Alongside his clinical training, Dr. Daniels earned an MBA in healthcare administration, an experience he describes as learning the “language of business” and finance. Today, his perspective combines the responsibilities of a practising physician with those of an owner and healthcare executive navigating growth, staffing, reimbursement pressure and long-term succession.
Contact Details
- Website: https://www.wetreatfeet.com/
- LinkedIn:https://www.linkedin.com/in/drmikeldaniels/
- Additional website: https://thepodiatryvoice.com/
- X: @DrMikelDaniels
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About the podcast
Voices in Health and Wellness features conversations at the intersection of medicine, lifestyle, and human potential, with clinicians, scientists, and thinkers shaping the future of care.
About Dr Andrew Greenland
UK-based medical doctor and founder of Greenland Medical, specialising in Integrative and Functional Medicine. Trained in both conventional and root-cause approaches, Andrew helps people optimise health, performance, and longevity, with a focus on cognitive resilience and healthy ageing.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Andrew Greenland (00:00):
Welcome back to Voices in Health and
Wellness, the podcast where wespeak with practitioners and
healthcare leaders about bothsides of model medicine, the
work we do with patients, butalso the realities of building
and running the organizationsbehind that care.
I'm your host, Dr.
Anthony Greenland, and today'sconversation is really about the
business of being a doctor.
Because clinicians receiveyears of training in how to look
after patients, but we're notnecessarily taught is how to
(00:22):
employ and lead teams, managecash flow, deal with insurance,
use technology, open additionallocations, create systems, and
ultimately build an organizationthat can grow beyond us as
individual practitioners.
My guest today has experiencedthat journey firsthand.
Dr.
Mike Daniels is a prodigistwith an MBA who serves as
president, CMO, and managingmember of WeTweet Producty,
(00:45):
sorry, WeTweetFeet Producty andWeTweetFeet MSO.
With that, Mike, I'd love towelcome you to the show.
Thank you very much for joiningme today.
Dr Mike Daniels (00:53):
Thank you.
I appreciate the invitation.
Dr Andrew Greenland (00:55):
So if we go right back to the beginning,
what drew you first intohealthcare in the first place?
Dr Mike Daniels (01:04):
My whole life, my mother told me I was going to
be a doctor, and when I got tocollege, I couldn't figure out
what anybody else did.
So I just, you know, kept goingin that direction.
My wife argues I should havebeen a lawyer, primarily because
she doesn't like to argue withme.
But it really honestly, it itwas just the way I was brought
up.
And I to this day wonder whatpeople do all day.
(01:27):
People sit in offices.
My wife's a school teacher, soat least I have a reference for
her.
But she talks about theadministrators, and I'm like,
what do they do?
They're always busy doingsomething.
And I can't figure it outbecause you know, in my day,
every 10 minutes I have a newmeeting all day long.
So I'm constantly moving.
And in between those, whenthere is time, which there never
(01:49):
is, you know, I have todocument those meetings.
So, you know, it's just one ofthose things to this day, I
don't know what else I could dobecause this is pretty much all
I know.
Dr Andrew Greenland (01:58):
Thank you.
Really helpful context.
So, of all the directions youcould have gone and taken within
healthcare, what was it aboutpodiatry that caught your
interest?
Dr Mike Daniels (02:06):
So, when I was very early in my college career,
my grandmother was a diabeticwho had a foot wound.
And I went with her to herpodiatrist appointment and met
her podiatrist, who was awonderful guy, um, and just was
really interested.
And he was very enthusiasticabout the profession.
So I then spent some time inthe office, and then uh during
my college time, I spent sometime working in a podiatrist's
(02:28):
office in Allentown,Pennsylvania, where I was in
college, and it just I justmoved in that direction, was all
I ever really wanted to do.
Um, I find it interesting whenyou look at the different
medical specialties, especiallyones that require different
schooling.
So, even between MDDO,dentists, chiropractors,
optometrists, you name it, um, alot of them applied to
(02:48):
different versions.
Uh, I'm the only one I know whoand only applied to podiatry
school.
That was it.
So I I I've been kind of onthis path since I was about 19
years old.
Dr Andrew Greenland (03:00):
Thank you.
So, from this point you weremaking about not really knowing
what anybody else did in theirprofessional work all the time,
when you were training, what didyou imagine your career was
going to look like when you kindof started out?
Dr Mike Daniels (03:11):
That's an excellent question.
I definitely thought my dayswould be shorter and my anxiety
level would be lower.
Uh, that has not worked out sowell for me.
Uh, I always tease that youknow, my goal in life was to
have a job where I didn't haveto work weekends and I didn't
have to have my name on myshirt.
Um, that didn't go so well forme because I do that too now.
(03:31):
But uh as I just kind ofprogressed through this whole
thing, uh it just developed intowhat it is.
I I don't really know what Iexpected.
I mean, you know, we didclinical work as residents, you
know, we had clinic days, and itwas funny because those were
the days we as residentsdespised.
We didn't want to go to clinic,we wanted to be in the
operating room.
That was, you know, that waswhere we wanted to learn.
(03:52):
Um, but you kind of get intothe flow.
So when I went into practice,it was actually a step backwards
for me because I was muchbusier in my resident clinic
than I was in my privatepractice when I started for you
know the good six months or so.
Dr Andrew Greenland (04:05):
And what surprised you most about the
reality of being a podiatrist?
Dr Mike Daniels (04:10):
I think the reality has changed over time.
I remember being surprised atwhat how much we were paid for
different things when I wasearly in my career.
And nowadays I'm surprised athow much people uh will do two
things.
Number one, trust Google overyou.
Um, and you know, number two isscoff at paying medical bills.
(04:32):
You know, people will go andspend a thousand dollars for
tires, but if they have a $50copay, I mean that's I always
say them's fighting wordssometimes.
Um, I don't make thosedecisions, I don't set their
copays.
Uh, but it it amazes me, youknow, at how people, and I don't
want to besmirch or anythingfor anybody else because you
know everybody's money is theirown, but sometimes I think
(04:53):
priorities are just kind of outof line.
Dr Andrew Greenland (04:57):
And at what point did owning your own
practice become something youwanted to pursue?
Was there like a turning pointwhere you thought, actually,
this is this is this is thedirection I want to go in here?
Dr Mike Daniels (05:06):
Um, so when I was finishing school, you know,
uh finishing residency, youknow, 25 years ago at this
point, um, there were really twodifferent ways you went.
You either started a practiceor you went to work for a
practice.
And the idea being if youworked for a practice, you would
either eventually buy in as apartner or you would leave and
buy somebody else's practice andcontinue to go on.
(05:26):
Um, and that was the vastmajority of practitioners at
that time.
Um, the concept of employedphysicians with health systems
and multi-specialty groups andeven with orthopedic groups uh
really didn't exist in anysignificant manner.
You know, hospitals were nothiring podiatrists, those sort
of things back in the day.
Nowadays, as somebody who hirespodiatrists on a fairly regular
(05:48):
basis, um, people no longer arelooking for anything other than
a job.
And they will literally tellyou that.
Um, you know, they have zerointerest in anything
business-wise, they have zerointerest in ownership.
Uh, when I started hiringdoctors 20 years ago, I would
get asked all the time, arethere partnership opportunities?
I never get asked that anymore.
(06:08):
Um, and quite frankly, it whenI was a resident, all of my
attendings were private practiceguys, so I saw how they all
worked.
Nowadays, people are beingtrained by employed physicians
for groups, so they're still notgetting that whole practice
management experience.
Um, and due to the way some ofour you know contracts get
structured and the way healthsystems do, and due to the Stark
(06:28):
Law regulations, um, I thinkthe way they get compensated is
very, very poorly understood.
Um, and it really hurts thembecause they have a lack of
understanding.
Dr Andrew Greenland (06:38):
Thank you.
And so for you, was it um thewanting the clinical
independence or seeing abusiness opportunity or wanting
to do things differently, or allof the above?
Dr Mike Daniels (06:47):
Uh I think probably a little bit all of the
above.
Um, you know, I I just neverimagined doing anything other
than you know going intopractice and taking care of
patients.
Um, I remember, you know, earlyin my schooling, so my first
year at Temple University, um,looking at my clinical doctors,
the podiatrists who work at theschool, most of the clinical
(07:08):
first year is spent not withactual podiatrists, it's spent
with PhDs who you know haveexperience in physiology or
anatomy or whatnot.
So you don't get that quitethat much, but you do get a
little bit.
They have, you know, you have acouple of classes where
podiatrists come in and teach,you know, basic biomechanics and
those sort of things.
Um, and some of these guys werefull-time employed by the
college, and some of them were,you know, they came in, they
(07:30):
taught a class, they had aprivate practice.
Um, and I decided prettyquickly that I didn't think I
wanted to be a teacher.
Um, I didn't think uh, youknow, stay sitting in the
audience thinking about what Iwas thinking about the people
talking to me, I'm like, I don'twant people thinking that about
me.
So I said, this isn't for me.
Um, so I, you know, I just wentoff.
And I would ask a lot ofquestions to our part-time uh
(07:52):
faculty, you know, who hadpractices about what they're
doing and why they do it.
And, you know, most of them itwas very consistent for them,
and some of them had a love forteaching, um, you know, and some
of them had some other ulteriormotives that that you know
would come out every once in awhile.
Um, but I felt very differentlyabout you know being in a
employed clinical space where Iwas responsible for just you
(08:13):
know one thing and didn't have,I guess, creative freedom or the
ability to practice within myin my true scope of practice.
Um, you know, there was we hadbiomechanic attendings, we had
infection attendings, we hadsurgery attendings, you know,
everybody wanted to work withthe surgery attendings, nobody
wanted to work with anybodyelse.
And I figured, well, that's notgood either.
So I kind of just pursued thiswhole thing.
(08:34):
And as I went on, I wasfortunate.
My residency director was aprivate practice doc.
So, you know, and he would tryto teach us all kinds of things.
Uh, you know, I I talked to hima couple weeks ago.
I'm still very grateful for theopportunity he gave me.
And uh, you know, I just movedin that direction.
And then after I startedworking, uh, when I started to
see what I was generating, and Istarted to see, well, what
(08:55):
percentage of what I wasgenerating was I actually
getting in benefit, I startedscratching my head and going,
well, it makes more sense tohave a lot of people working for
you so you can take you knowpieces of everything than to
just try to do it all yourself.
Um, I I think every day I thinkthat might have been a mistake.
Uh, because sometimes I thinkmy life would be a lot easier if
it was just me.
Um, but the ability to be asingle solo practitioner doctor
(09:19):
in this in this day and age isso challenging because you're
just getting eaten alive withfixed costs.
Our reimbursement is notincreasing, it is declining both
in actual and inflationadjusted dollars.
And it just gets harder andharder to keep the lights on
every day.
So I don't know how the singlepractice guys are doing it.
And if you look at ourdemographic as podiatrists, most
of the podiatrists still insingle or just dual practice are
(09:41):
my age and older.
The younger guys aren't doingthat.
Very, very few.
And if they are, they'refinding a niche.
Um, you know, there's a wholeconcept of concierge pediatry,
which is trying to go, andthat's doctors who take no
insurance.
Some of them travel and go topeople's homes, some of them
have an office.
And, you know, everybody's kindof looking to find their place.
Uh, I'm too old to lookanymore, so I'm kind of stuck
(10:03):
where I am, and I think thisone's gonna ride this wave until
I grow until I retire.
But um it's it gets to be tothe point where you know you
have to kind of figure out, youknow, where does the money you
you make come from?
Because if you don't know whereit comes from, you don't know
how you get it, in which casemaybe you don't even appreciate
it.
And I think sometimes doctorshave lost the ability to
(10:25):
appreciate their patientsbecause of that.
I mean, listen, the systembeats the daylights out of you,
it really beats the humanity outof you.
So sometimes it's hard toremember that, you know, it
really has nothing to do withme.
It's all about the patient.
Dr Andrew Greenland (10:39):
Thank you.
So thinking about that timewhen you were you know wanting
to open your own practice, onething I'd realized in medicine
or any clinical training is thatwe don't get any business
training at all.
And I guess we're eitherworking it out from other people
around you who understand thebusiness side of medicine, or
you're kind of figuring it outon your own.
Which which camp were you in?
Dr Mike Daniels (10:58):
So I joined uh a gentleman in practice uh when
I first got out of residency.
Um he had been there for 25 orso years by himself, uh sitting
in a you know at the same officebasically.
And you know, I came in and Iwas, you know, all full of spit
and vinegar and wanting to savethe world one foot, one toe at a
time, or cure the world onesoul at a time, maybe.
Um and you know, I very, veryquickly realized that um he
(11:22):
didn't really do that much uh asfar as what patients' needs
were, what the services we couldoffer or could provide patients
were.
So, you know, two years intothis thing, I was making, I was
generating more revenue than hewas, and I was making more money
than he was.
So, you know, I foolishly tooka pay cut and became a partner.
And you know, that kind ofstarted my journey at that
(11:43):
point.
Um, and I really didn't see anyother way.
I explored the possibility ofbuying a practice, but I I had
you know somebody there who wasteaching me, you know, how to
practice.
It turns out a lot of it wasincorrect, which you hear a lot
of.
Um, people are just not toldthe right thing because a lot of
doctors, you know, after theages really, you know, flew by
(12:03):
the seat of their pants.
Um, if you go to lectures andyou you talk to older doctors
who are on the lecture circuittalking about practice
management aspects, they'll tellyou crazy stories about how
when they first got there andstarted in practice, there were
four codes, and they paid someyou know person $10 an hour just
to select the code.
And they figured, well, I coulddo that myself and save the
(12:24):
money, and you know, and alljust these crazy, crazy stories
about what it is.
And you know, as time has goneon and reimbursement has not
kept up with inflation and hasactually been cut, the
regulation and and uh andspecificity of medical records
for the purposes of billing hasjust gone crazy.
Um, here, for example, uh CMS'suh audit criteria is
(12:47):
perfection.
If you send a medical recordand it is not perfect, they will
do a clawback.
You know, it's no good try,it's no, okay, we understand the
patient needed the service,it's oh you did it.
It's no no no.
There are 27 things here, andyou only have 26 of them, so we
are clawing back the money,which is an impossible standard.
And they know it, and doctorsknow it, and that's why
(13:09):
everybody expects to have moneyclawed back, but they're already
paying us less for theseservices, and now they're taking
more back, and it's just anunsustainable model in that
regard.
So, going back to where thediscussion started is none of
that existed when I was startingout trying to figure this out.
Um, I don't know, I might havegiven up and gone to work at
McDonald's at that point becauseit's it's absolutely crazy.
(13:31):
I generally worry about thedoctors coming out of residency
and coming out of training now,what they're gonna do.
Because I mean, I neverimagined it could get to this.
So I can't even imagine whatthe next 20 years is gonna look
like.
Uh, it is a little bit scary.
So, you know, I think lookingat back at it, uh, I didn't
really know anything, and it wasprobably a good thing because I
(13:54):
think sometimes you can, youknow, know enough to be
dangerous.
Um, and I've just developedthis and I try to explain to our
younger doctors how thesethings are working, but
sometimes it's you know it'slike a deer in headlights, and
you know, every time I hear it,it's like, well, I don't have an
MBA.
I'm like, okay, well, I didn'thave an MBA when I started
either.
I couldn't answer any of thesequestions, that's why I got one.
And guess what?
An MBA taught me I reallydidn't know what I was doing.
(14:16):
That's all it really taught me.
So, you know, you just and andthe last thing I tell people is
I have probably made everysingle expensive mistake you can
make in podiatry along the way.
If there's a mistake that costsmoney, I've made it.
So you learn a lot from thelived experience as well.
So, you know, I have justmatured into this position.
(14:37):
I don't think this was ever anactual goal.
I don't think I'm ever going toarrive at, you know, the end at
the end of the road saying, Igot there.
I think my road's just gonnaend one day, and I'm gonna say,
okay, and you know, do what allpeople do and retire and move to
Florida.
Dr Andrew Greenland (14:52):
Thank you.
Really great insight.
So you just mentioned the MBAin talking.
I'm just curious to know whatdid it do for you and how has it
helped you over the years?
Dr Mike Daniels (15:01):
Um, the best way I can explain it is my MBA
program was more like a foreignlanguage degree.
Um, the the language ofbusiness and the language of
finance is very, very differentthan the language of medicine.
And you you get into a group ofdoctors who are generally the
smartest people in the room, andthey start talking to people
(15:23):
who now run hospitals.
Now, when I was training andwhen I was early in my career,
most of the hospitals were runby doctors.
Most of the C-suite weredoctors.
Now you have one doctor in theC-suite, and nobody else there
has any medical degrees.
It's all business guys.
Um, and when I was, I don'tknow, about five or six years
old or so, I started serving onthe perioperative governance
committee for the hospital.
(15:44):
And that would be a committee,there would be admins there,
there would be representativesfrom the different specialties
there.
And I remember sitting in thatclass and sitting in that
meeting, and people who reallyhad no animosity towards each
other were screaming at eachother because they weren't even
talking about the same thing.
And and when I got the languageskills from my MBA to realize
(16:05):
what the business people weresaying and why the I knew why
the doctor people didn'tunderstand, it was like an
epiphany for me.
So now, whenever I'm in thosethings and I I sit there and I
laugh because I love how youknow the they'll come, the the
admins will come in and say,Well, the hospital did better.
We only lost four milliondollars last year.
And then you look on the andthen you look on the PL and
(16:26):
there's you know $17 millionworth of depreciation.
Like, well, you don't lose fourmillion dollars because you
didn't spend that money.
And like everybody's like, oh,well, the hospital's losing
money, we're gonna go bankrupt.
No, it's paper loss, and theydon't understand.
And the business people eitherdon't understand that the
doctors don't understand or arehappy with them being
(16:46):
uninformed.
I don't I never know which oneit is.
But it's just it's learningthose language skills to be able
to actually sit there andunderstand what's going on when
people tell you stuff, andbasically to understand when
you're being lied to.
Dr Andrew Greenland (17:00):
So is the MBA something you pursued
because of problems you'reencountering in the practice, or
had you always wanted a formalbusiness as education to kind of
cement what you were doing?
Dr Mike Daniels (17:10):
Um so I was an economics minor in college,
which taught me absolutelynothing about business.
Um, but you know, if you wantto talk about you know supply
and demand or laugh at hercurves, I'm your guy.
Um, so but I I the funny thingis, I was talking about this the
other day with with acolleague, is um I loved my
economics classes.
Everything just made completesense to me.
(17:31):
I really didn't have to studyfor them.
All I had to do was learn thevocabulary, and it was easy
because you know, I mean,listen, everything actually
comes from supply and demand,and then you just break off.
Uh, it's kind of it's kind oflike physics uh with Einstein's
theory of relativity.
Everything starts with that andthen breaks off, and you start
breaking the components downinto their other components.
You can do exactly the samething in these circumstances.
(17:52):
So when I started running thepractice myself, when I bought
out my original partner, um, andI told people when I got to my
first you know million dollarsof revenue year, and I was
thinking I was the greatestthing since sliced bread, um, I
began to realize in talking,especially my accountants, that
I had no idea what that meant.
And I had no idea where ourdollars were going, and I had no
(18:12):
idea how much taxes I was goingto owe.
I didn't understand any of it.
And I would go to meetings withmy accountant, and the
accountants would just starttalking, and I was they might
have been, I always say theywere like the teachers from the
comics, uh, the comic peanuts.
Charlie Brown and Peanuts arevery familiar with that.
Well, every time they had acartoon of that, and they had
the teacher, the teacher wasjust a trombone going, wah, wah,
(18:34):
wah, wah, wah.
And that's what the accountantsounded like to me at that
point.
So, you know, I was able to dothis, and then, you know, last
year, the year before, I'msitting in a meeting with our
accountants, and I said, youknow, oh, we need to put this on
the balance sheet because thisis a single-time use and it's an
abnormal thing, and it's notreally an expense.
And the junior accountant'slike, no, no, no, you paid it as
(18:55):
an expense.
And then the senior accountantsaid, No, no, we can do that, we
can move that over.
And part of it was because Iwas trying to, you know,
increase valuation uh by youknow increasing profits by
moving costs off the PL.
Um, but again, I knew to dothat, and the the younger
accountant didn't quite get it.
So it's kind of one of thesethings where uh I'm glad I did
it.
I actually did enjoy businessschool.
(19:17):
Uh I was I did a cohort, so Iwas basically it was all done at
home.
Um, I would just sit there andwrite, and I would come home
every day from work, and fromlike seven to nine, I would sit
there and I would write, andthen I'd spend you know four or
five hours on each day duringthe weekend, and I would just
sit there and write.
And you know, I got through it.
Um, and I actually didn'tstruggle at all.
I really enjoyed it.
And I'm still kind of toyingsomeday with the idea of maybe
(19:39):
going back in uh my health, myMBA's in healthcare
administration, maybe getting aconcentration with finance, um,
because I'm a glutton forpunishment, I guess.
I don't know, but um, I stilldon't think I completely
understand corporate finance, atleast understand it enough to
really and I would like to learnmore.
But I'm also from thegeneration where if you didn't
understand something, you wentto the library and got a book.
(19:59):
You know, you didn't whip yourphone out and have you know
Google tell you in 12 seconds.
So um that's why I went back toschool because that was me
getting a book.
It was me getting the educationthat I would have had to Google
and try to figure out andwouldn't be able to comprehend.
Dr Andrew Greenland (20:14):
Okay.
So in your evolution then, whendid your thinking start moving
from I own a practice to I couldactually build an organization
here?
Dr Mike Daniels (20:23):
Uh that just mature by itself, too.
Um, when I was first inpractice, um the idea of
in-office surgical suites wasreally kind of coming into its
own.
Um, and back then the surgicalsuites were really well
compensated.
And I said to myself, well, whyam I giving all this money to
the hospital surgery center whenwe can just have our own?
So that evolved.
(20:44):
There was already durablemedical equipment when I got
there.
We were already doing diabeticshoes and cam boots and some
braces and those sort of things.
Um, so that aspect was there,but you know, we've now expanded
that to wound supplies andcompression garments and things
along those lines.
Um, and then you know, we'vestarted a clinical trials arm.
Um that's a revenue generatorand a patient generator as well.
(21:05):
Um, part of it is because wetake projects that we're
interested in, and secondarilyis you know, it helps to you
know put our brand out there forthat.
Um, and then along the way, andagain, this is around 2010, um,
we were really unhappy withwhere our billing companies
were.
So uh a friend of mine and Istarted our own billing company,
(21:26):
and we started with twoclients, his practice and my
practice.
And we grew it and we had abouta dozen clients at one point.
Um, but it actually started towind down.
And when we moved out of theour our private market, where we
just basically practice into amedical services organization,
we folded the medical billingcompany and rolled it into the
medical service organization andgot rid of the last of our
(21:47):
clients.
So now the only billing clientwe have is us, um, which has
made life a little bit easierfor us.
But it's that whole kind ofprogression of just adding
services that I talk about now,I consider them service line.
Where back then I didn't knowwhat a service line was from a
you know from a bus stop.
Um so as we got these servicelines added and we started to
(22:08):
look at added value for thesethings, that's kind of the
progression that we go.
So to fight insurance declinein reimbursement, we look to
figure out is what are ourpatients getting that we're not
providing and what can weprovide them?
So we get the dollars.
I mean, they're spending itanyway.
We're not looking to havepeople spend more money than
necessary.
But if you're already gettingit and you're going to XYZ
(22:31):
distributor, and I can do it inmy office and you know have some
profitability with it, well,that's what I want to do.
And that's where this wholething blew out of is it's okay,
what can we add now thatgenerates revenue to displace
the decline that we're seeingand to provide better service
for patients because it's awin-win for us.
And you know, to this day,there are lots of practices that
(22:52):
don't do a whole bunch of thosethings.
I think they're really missingout.
One is they're missing out onrevenue sources, but number two
is when you give somebody aprescription and send them out
the door, they are far morelikely to lose it and not do it
than you are when you give themthe product in the office.
So compliance goes up, sosatisfaction goes up, and all of
that is super important thesedays because people go on Google
(23:15):
and rank you now.
Uh, you know, and you know, ifeverybody's, you know, if if if
you know somebody says, Oh, youknow, my doctor got me my
diabetic shoes, and I was like,Well, well, I had to go to this
pharmacy and they didn't fitright, and you can see the
difference.
So, aside from being revenuegeneration now, it's also
practice promoting.
And, you know, anything that wecan do that promotes the
(23:36):
practice for free or promotesthe practice where we get paid
to do it, like clinical trials,we're all for that and we take
advantage of that.
Dr Andrew Greenland (23:45):
Thank you.
And is it um which is thebiggest leap?
Is it from one practice to thesecond office, or is there
somewhere else further down theline where it becomes the
biggest challenge for you fordoing this?
Dr Mike Daniels (23:55):
The biggest challenge is just the concept of
expansion and whether or notyou're going to do it through
acquisition or de novodevelopment.
Um, I personally am a bigbeliever in acquisition.
Um, you know, it's nice to buya revenue source, it's nice to
buy an office where everything'salready equipped and you just
have to update, as opposed toyou know, going into a blank
(24:16):
space and imagining what itcould be and building something.
Um, again, you can tell whatsomebody did, and you know,
statistically we always talkabout it.
You buy a practice, 10% of thepopulation walks out the day you
walk in because they're onlycoming to see the other doctor,
and it's not convenient forthem, so they're going to go
somewhere that's convenient ifthey can't see the same doctor
they're soon.
(24:37):
Um, so I but again, and Iaccount for that whenever we do
an acquisition, but I thinkthat's better because you have a
revenue source and you canactually put together a budget
for that and figure out whetheror not you can improve that.
And again, a lot of that isgoing back to adding ancillaries
to improve revenue.
But um, when you start cold,uh, unless it's an area with a
(24:59):
huge demand, you know, it's likeany business that you're
starting.
And you know, if you want tocompete against the neighbor, I
mean there's nothing wrong withthat, but is that always the
best medicine?
Um, and and I personally don'tthink so in most circumstances.
So, you know, I think the theconcept of just I think
everybody wants to be biggeruntil they figure out what that
really means.
(25:19):
But when you decide to getbigger, do you do it by
acquisition?
Uh, do you do it by de novo, orcan you expand your current
practice beyond what's currentlybeing done?
Uh, because if you talk toanybody, most people will tell
you that they're maxed anyway.
Nobody ever seems to have youknow extra room.
Uh, you know, nobody has someextra time there to throw in and
do it.
And everybody's just you knowcrazed.
(25:40):
And we had this exact thinghappen in our office this week.
We have added a balance andfall prevention program to our
practice.
Um, and you know, to make sureit takes the medical assistant
about a minute to just run thepatients get an iPad basically
and they fill out, you know, Ithink half a dozen questions,
not a big deal.
The medical assistants spendyou know about a minute doing
(26:01):
you know, balance testing, andthen we come in and we review
all the results and we discussthem with the patient and you
know put together treatmentplans to prevent falls.
Um it's actually a CDC and CMSpromoted program.
Um, our admins in our practicewere freaking out because nobody
has time to do anything, andthis is gonna add so much time.
I asked the medical assistantthat works with me regularly,
(26:23):
I'm like, what's going on here?
Is this hard?
He goes, No, it takes me lessthan a minute.
So if you're a minute and we'readding revenue, we're gonna
prevent falls, which is gonnahelp our patients, and our
admins are freaking out about itand saying, Well, it's not
enough.
I'm like, Well, I'm sorry, it'shard to find enough.
And if you ever do, please letme know because I haven't.
What we're trying to do is keepthe doors open, and this is one
(26:44):
more way that we can helppeople and keep the doors open
at the same time.
So it's those decisions becauseinevitably nobody likes change,
and it doesn't matter how goodthe change is, the first
reaction is usually negative.
Oh, we don't want change,change is bad.
Change means more work, changechange means more complaints,
more issues.
Yes, but again, change is alsohow you grow.
(27:06):
You can't grow without change.
And yeah, and I know gettingthe expansion bug, those are the
sort of things you need to lookat.
Which one of those three?
And if you do that and you canmake a decision and you can be
happy with your decision, thensometimes you're a better man
than me.
Dr Andrew Greenland (27:22):
So bring us up to date with where you are
now.
What does um we treat feet looklike today compared to that
first practice?
Dr Mike Daniels (27:29):
Uh so we are now uh, you know, as we say,
we're now a platform, that's whywe turned into a medical
services organization.
So we actually now have anownership structure where we
have a non-physician owner.
Um, and there's corporatepractice and medicine laws and
things like that that are wellbeyond my understanding or my
pay grade uh to make it legal.
But that's the way it has tobe.
So, you know, we have theability to compensate our you
(27:53):
know really good employees andturn them into owners, um, which
is a big change from where itis.
And you know, I came in and Ipaid, you know, I wanted half
the practice, so I paid you knowhalf a year's gross, um, which
nowadays is insane to thinkabout given what cost runs are
for practices.
Um, so you know, we can dothat.
Um, it allows us to give equitypieces to physician in our uh
(28:16):
area um without having them goout and borrow a million dollars
to buy 20% or whatever.
So uh we can do it to themwithout with adding significant
structured debt through a coupleof different ways that we go
about doing that.
So, you know, breaking it downand then breaking it down into
different service lines, and youknow, you can't do every
service line in every office,but what are the crucial or the
(28:38):
essential ones that have to belocated there?
Um, and then there's just theshifting demographic of medicine
in general, with you know,higher deductibles and higher
copays and those sort of things,which start to limit treatment
options for patients, um, youknow, which is hard.
I mean, if you thinksomething's better for patient
and they can't afford it, um,what are you gonna do?
And we we had those decisionsbefore, but not like we do
(29:00):
today.
So those things all combinedtogether have now allowed us to
do that, have allowed us to getto our current state.
And the idea being um, youknow, two offices cost as much,
cost more than one office, buttwo offices don't cost as much
as two one offices.
And then three offices costmore, but they don't cost as
much as two two offices, and itjust grows from there.
(29:22):
So by doing economies of scaleand reducing your overhead
burden, um, that's the way tocontinue to grow.
And and again, you know, um asphysicians, we're not exactly a
sympathetic group when it comesto you know earnings.
Uh, people are not reallyworried about their doctor not
being able to eat dinnertomorrow night because their the
(29:43):
reimbursement declined.
So if you're gonna figure outhow to be able to run the place
and you're gonna figure out howto be able to maintain
everything where every year therent goes up and every year the
employees need raises, and everyyear health insurance goes up,
and you know, malpractice goesup every year, um, you have to
figure out how you're going todo that.
Because the previous answer wasjust see more patients.
(30:04):
Well, I'll tell you, therearen't enough hours in the day
for me to see more patientsanymore.
So I got to figure it outsomewhere else.
And that's kind of you knowwhere we've moved it into, and
that's the biggest differencenow.
Because again, I got out, Ifigured I could see everybody in
the world, I can see 100patients a day, and I'd be fine.
Well, no, I can't.
I'm too old for that now.
I don't move that quickly.
Um, but even so, I you know,when you see too many patients,
(30:25):
the care you provide starts tosuffer, and that's unacceptable
to me too.
So we try to make sure thatwe're doing everything we can to
keep the lights on while stillproviding the highest level of
care that we can.
Because if you start tocompromise care, then you you
might as well go out of businessbecause you've done.
Dr Andrew Greenland (30:42):
And there's a follow-up to that, and you
may have partially alreadyanswered this, so forgive me.
But why is the overhead ofrunning an insurance-based
medical practice in the US sohigh?
Obviously, I'm in the UK, so Idon't have this understanding of
the model quite so much.
And also, what are people doingwrong that are not making it
work?
Dr Mike Daniels (31:00):
Uh, quite frankly, I'll tell you, I don't
think there are people whoaren't making it work because
they're doing it wrong.
I think the people who aredoing it wrong are just getting
in trouble down the road.
Uh, because people don't tendto be under, they tend to be
over.
Um, it I joke about this allthe time.
It's like sometimes I think,well, maybe if I just charged
every patient 50 bucks wheneverthey walked in the door and took
no insurance, I would be betteroff because first we have forms
(31:23):
that have to be filled out andinsurance forms that have to be
copied and have to be scanned.
Then I have to see the patient,do a note, and then figure out
what I did and how that relatesto the billing codes that I
choose.
Those then go from you know,from our section in the
electronic health record to thebilling section, and they then
have to review it, make surethat everything from their
address, phone number, date ofbirth, and all the coding is
(31:45):
correct.
Uh, they're looking formodifiers and other things, I
see different ICD tens, becauseyou can have two ICD tens that
say the same thing, but one ispaid and one isn't.
If you don't have the rightdiagnosis, it won't get paid, so
they have to scrub those.
So we then send those to aclearinghouse.
A clearing house, I don't know,even know, other than being a
middleman and exchanging money,I'm not really sure what they
do.
(32:05):
But they then process it andsend it to the third party
payers, and the third partypayers, you know, then decide to
pay us or decide not to pay us,and that's where it gets to be
expensive.
So every single step you havecosts you money.
So, and there is zero way toeliminate any of that because
I've done everything I can totry to.
(32:26):
Um, at the end of the day, canI streamline some of them?
Yes.
Is technology and AI helping?
Yes, but every single stepcosts money.
So think of it this way the thecare you provide the patient is
only one part of a very longchain, and that's why everything
in the US costs so much,because everybody has their hand
(32:47):
in the line and everybody getspaid along the way.
Um, and then you know, talkingabout billing and that with a
lot of doctors is you knowcommitting blasphemy.
So, you know, dirty money is adirty word in medicine.
So, you know, nobody reallywants to take the time to figure
that out, and that's reallywhere the problem is.
Dr Andrew Greenland (33:06):
Yeah, when we first connected, I think you
said one of the biggestoperational challenges was
phones.
Tell us what's happening there.
Dr Mike Daniels (33:13):
I'm sorry.
Dr Andrew Greenland (33:14):
I think when we first connected, you
said one of the biggestoperational challenges was
phones.
So can you sort of tell us alittle bit more about where
what's what's the problem there?
Dr Mike Daniels (33:23):
Well, I think I think it's way too easy to get
bogged down in um in the patientcare aspect and realize that at
the end of the day, if youcan't keep the lights on, you
can't help patients.
So, you know, the focus isalways on the patient.
We're all taught to do that, weall do that.
I mean, it's almost just uh gutreactions at this point, and we
(33:44):
know nothing else to do.
But again, sometimes you'remissing the bigger picture, and
that's that's really what'sgoing on.
So uh you really need to stay,you know, focused on the medical
part, and then either youbetter have somebody like me who
can focus on the business partto make sure everything drives,
or you're gonna end up introuble.
And I think that's primarilywhat I mean by focus.
Dr Andrew Greenland (34:09):
So, with all your business experience and
where you are in your umprofessional journey, what are
the things that still keep youup at night in running this
show?
Dr Mike Daniels (34:18):
So I, you know, again, there there are a
handful of things that do.
Uh, you know, obviously, isthere enough money this week to
make payroll is always on mymind.
Um, you know, I I I tend towork now in you know short,
maybe you know, three to fiveday blocks of revenue generation
because we have to make surethat we can pay all our bills so
that keeps me up at night.
Uh patients who aren't doingwell still keep me up at night.
(34:40):
Um, it doesn't matter if I hadanything to do with it or not.
You know, I will lie there andthink about what else we can do
differently, do differently forpeople.
Um, you know, and then again inthe US, you know it's a very
litigious society.
So, you know, I sit at dinnerwith the TV on and there's 17
doctor, 17 lawyer commercialsscreaming, did your doctor make
a medical mistake?
Call me, I'll get you justice.
(35:01):
I don't know how justice becamea synonym for money, uh, but
somewhere along the line it didhere.
So those are the sort of thingsthat keep me up.
That and then staffing issues,and it doesn't matter, physician
staffing issues are always anissue, and support staff issues
are always an issue.
Um, it seems like we never haveenough of either.
Um, and doctors hanging ashingle and sitting in an office
(35:22):
for 30 years is is over.
There's a ton of mobility inpeople's careers now in
medicine.
And uh I've had people tell usthat you know, our initial
contract offer, so somebodycoming out of residency, we're
gonna offer them a three-yearcontract.
Well, three years is too longbecause I'm not sure I want to
stay there for three years.
What you have a hundred, youknow, you're $500,000 in debt
(35:42):
and you don't want a guaranteedjob for three years?
That doesn't make any sense tome.
So, you know, the grass isgreener somewhere else, I guess.
Um, but it shocks me thatpeople are now just blatant
about the fact that they don'tintend to spend their career
there.
And you know, you're you you'rea doctor, you've gone to the
doctor.
People like to go to the samedoctor, they they like to get
(36:05):
that comfort level, especiallyin a profession like ours, where
we do have patients thatreceive four to five times a
year, every year for years.
Um, you know, I I assume it'ssimilar in primary care where
you know you're seeing thepatients whatever the protocol
is for whatever their conditionsare.
Um, but again, I hear from mypatients when their intern is
move on and they can't find youprimary care doctors or they
(36:26):
don't like the new one and hadthe old one for so long, and
those sort of things.
So I I worry about how to makesure that we're maintaining the
same kind of um practiceintegrity, I guess, that people
grew up relying on because it'sreally not there anymore.
Dr Andrew Greenland (36:45):
So if I gave you a magic wand, then you
could fix anything in thebusiness overnight.
What would that be?
Dr Mike Daniels (36:50):
Oh, I I would just double our revenue.
I think that would uh solve allof my problems.
Uh if I could just double myrevenue overnight, um, that that
would be nice.
Uh, you know, and other thanthat, it's things that come up
as time goes on.
Um, we're here in Maryland acouple of years ago, there was
uh a big cargo ship that ran andliterally knocked one of our
major bridges into the water.
(37:11):
You may have heard about it.
Um and we had three officeswithin 15 miles of that bridge,
and everything just stoppedbecause people couldn't get
anywhere because they couldn'tget to the other side of you
know we call it of the bay.
And uh, you know, our revenuewithin the first three months
after that in those threeoffices dropped like 70%.
(37:32):
It was crazy.
And of course, now people kindof figure out how to do things
and those sort of things.
But in the beginning, it wasall very much um uh that you
know, people couldn't figure itout.
So we had doctors just sittingthere.
Dr Andrew Greenland (37:47):
You've had a pretty long, successful
career.
Um, if you were to have yourtime again tomorrow, would you
do anything differently?
Dr Mike Daniels (37:54):
Yes.
When I graduated from college,I would have gone to work in the
mailroom at Goldman Sachs andworked my way up.
I would have worked less andmade more and probably been
retired by now.
Um, you know, you hear allthese Wall Street the crazy
hours.
And if you talk to privateequity guys, the crazy hours
they make their juniorassociates work.
And I'm like, well, that's justThursday.
I don't know what you'recomplaining about.
(38:14):
You know, oh well, we getemails at 11 o'clock at night.
I'm like, we get calls at 11o'clock at night.
I have to leave and go to thehospital.
So I always say, yeah, Iprobably would, if I had half a
brain in my head, I probablywouldn't do this, despite the
fact that I'm not sure whatthey're doing all day that's
taking them so long.
They're looking atspreadsheets.
I don't know what people didbefore spreadsheets, but uh I
don't know.
But it seems like uh thatprobably would be a better way.
(38:36):
Maybe I'd be sitting in theHamptons town instead of uh here
in Maryland.
Dr Andrew Greenland (38:40):
But on a serious note, if you uh having
your time again and you werewithin you were staying within
this career, would you doanything differently um from
this career perspective?
Dr Mike Daniels (38:50):
Um I I might have looked a little bit um a
little bit more at maybe doinggoing the allopathic career
route.
Um, you know, I I I have thiskind of administration thing,
and I in the back of my mind Ialways think, well, I could run
this hospital better than thoseguys.
So, you know, but I I don'thave the background to do it.
So um I I don't know.
(39:10):
That could have been something,but uh at this point, no, not
really.
Um I'm not I don't have anyregrets about choosing to be a
podiatrist, uh you know, maybebeing a doctor in general, but I
honestly don't think it wouldbe any different if I was a
dermatologist.
Dr Andrew Greenland (39:26):
And what are the future?
Where is um WeTreat Feet goingto be in the next 12 months or
so?
Do you have any plans for thebusiness and plans for what you
want to do with it?
Dr Mike Daniels (39:34):
Well, I mean, again, uh, you know, I'm much
closer to the end of my careerthan the beginning of my career.
So, you know, I'm you knowshaping out my my exit strategy,
and there's no me to come byme.
So, you know, one of a coupleof things is gonna have to
happen.
You know, one is I'm gonna haveto you know become a part of a
larger group, whether that beyou know through purchase of
(39:54):
equity and you know, being uh uha tuck-in, or whether that you
know being a format, uh platformformat for a company, maybe
that way.
Um, you know, do we startselling off pieces and you know,
we buy this piece and you takethat piece and that?
Um, you know, do I just youknow close the door, turn off
(40:14):
the lights and say buy one day?
So, you know, those are thesort of things they're growing.
I think realistically, based onthe market, is we'll get
acquired by somebody much, muchlarger than us one.
There's a about a half a dozento a dozen uh companies now
acquiring podiatry practices andand you know forming these
large groups, two or three andfour hundred doctors.
And I think at some point we'llget we'll get gobbled up by
(40:36):
them.
Um, not really sure what thatwill mean for me.
Uh, you know, would I just goback to being a regular plain
old doctor coming in at you know8:30 and leaving it for?
I don't know, maybe I would.
Would I then start to you knowrise in administration and and
rise in the corporate structurethere?
Maybe I would.
Maybe it's too late to do that.
I I don't know.
Um, you know, needs to say, Iyou know, I'm not 100% sure what
(40:57):
I'm gonna do on Monday yet.
So I don't know if I can thinkabout 12 months down the road.
But uh again, at the end of theday, um I am starting to really
seriously think about my exitstrategy because they say you
got to do that at you know, youknow, three to five years ahead
of time.
So, you know, I'm thinking I'mgonna be around another eight or
ten years.
I really need to put somethingin place.
Dr Andrew Greenland (41:18):
Mike, with that, I'd love to thank you so
much for joining us today.
I've really enjoyed theconversation.
I really uh um what I wouldparticularly appreciate is your
perspective that you're lookingat healthcare from both sides.
So the responsibility of beinga physician, but also delivering
good patient care.
And it's been so interestinghearing you know how you've
built and scaled your businessand your perspectives on running
it from where you stand.
(41:39):
So it's been a greatconversation.
Thank you very much indeed fortalking to me today.
Dr Mike Daniels (41:44):
Thank you for having me.
Welcome back to Voices in Health and
Wellness, the podcast where wespeak with practitioners and
healthcare leaders about bothsides of model medicine, the
work we do with patients, butalso the realities of building
and running the organizationsbehind that care.
I'm your host, Dr.
Anthony Greenland, and today'sconversation is really about the
business of being a doctor.
Because clinicians receiveyears of training in how to look
after patients, but we're notnecessarily taught is how to
(00:22):
employ and lead teams, managecash flow, deal with insurance,
use technology, open additionallocations, create systems, and
ultimately build an organizationthat can grow beyond us as
individual practitioners.
My guest today has experiencedthat journey firsthand.
Dr.
Mike Daniels is a prodigistwith an MBA who serves as
president, CMO, and managingmember of WeTweet Producty,
(00:45):
sorry, WeTweetFeet Producty andWeTweetFeet MSO.
With that, Mike, I'd love towelcome you to the show.
Thank you very much for joiningme today.
Dr Mike Daniels (00:53):
Thank you.
I appreciate the invitation.
Dr Andrew Greenland (00:55):
So if we go right back to the beginning,
what drew you first intohealthcare in the first place?
Dr Mike Daniels (01:04):
My whole life, my mother told me I was going to
be a doctor, and when I got tocollege, I couldn't figure out
what anybody else did.
So I just, you know, kept goingin that direction.
My wife argues I should havebeen a lawyer, primarily because
she doesn't like to argue withme.
But it really honestly, it itwas just the way I was brought
up.
And I to this day wonder whatpeople do all day.
(01:27):
People sit in offices.
My wife's a school teacher, soat least I have a reference for
her.
But she talks about theadministrators, and I'm like,
what do they do?
They're always busy doingsomething.
And I can't figure it outbecause you know, in my day,
every 10 minutes I have a newmeeting all day long.
So I'm constantly moving.
And in between those, whenthere is time, which there never
(01:49):
is, you know, I have todocument those meetings.
So, you know, it's just one ofthose things to this day, I
don't know what else I could dobecause this is pretty much all
I know.
Dr Andrew Greenland (01:58):
Thank you.
Really helpful context.
So, of all the directions youcould have gone and taken within
healthcare, what was it aboutpodiatry that caught your
interest?
Dr Mike Daniels (02:06):
So, when I was very early in my college career,
my grandmother was a diabeticwho had a foot wound.
And I went with her to herpodiatrist appointment and met
her podiatrist, who was awonderful guy, um, and just was
really interested.
And he was very enthusiasticabout the profession.
So I then spent some time inthe office, and then uh during
my college time, I spent sometime working in a podiatrist's
(02:28):
office in Allentown,Pennsylvania, where I was in
college, and it just I justmoved in that direction, was all
I ever really wanted to do.
Um, I find it interesting whenyou look at the different
medical specialties, especiallyones that require different
schooling.
So, even between MDDO,dentists, chiropractors,
optometrists, you name it, um, alot of them applied to
(02:48):
different versions.
Uh, I'm the only one I know whoand only applied to podiatry
school.
That was it.
So I I I've been kind of onthis path since I was about 19
years old.
Dr Andrew Greenland (03:00):
Thank you.
So, from this point you weremaking about not really knowing
what anybody else did in theirprofessional work all the time,
when you were training, what didyou imagine your career was
going to look like when you kindof started out?
Dr Mike Daniels (03:11):
That's an excellent question.
I definitely thought my dayswould be shorter and my anxiety
level would be lower.
Uh, that has not worked out sowell for me.
Uh, I always tease that youknow, my goal in life was to
have a job where I didn't haveto work weekends and I didn't
have to have my name on myshirt.
Um, that didn't go so well forme because I do that too now.
(03:31):
But uh as I just kind ofprogressed through this whole
thing, uh it just developed intowhat it is.
I I don't really know what Iexpected.
I mean, you know, we didclinical work as residents, you
know, we had clinic days, and itwas funny because those were
the days we as residentsdespised.
We didn't want to go to clinic,we wanted to be in the
operating room.
That was, you know, that waswhere we wanted to learn.
(03:52):
Um, but you kind of get intothe flow.
So when I went into practice,it was actually a step backwards
for me because I was muchbusier in my resident clinic
than I was in my privatepractice when I started for you
know the good six months or so.
Dr Andrew Greenland (04:05):
And what surprised you most about the
reality of being a podiatrist?
Dr Mike Daniels (04:10):
I think the reality has changed over time.
I remember being surprised atwhat how much we were paid for
different things when I wasearly in my career.
And nowadays I'm surprised athow much people uh will do two
things.
Number one, trust Google overyou.
Um, and you know, number two isscoff at paying medical bills.
(04:32):
You know, people will go andspend a thousand dollars for
tires, but if they have a $50copay, I mean that's I always
say them's fighting wordssometimes.
Um, I don't make thosedecisions, I don't set their
copays.
Uh, but it it amazes me, youknow, at how people, and I don't
want to besmirch or anythingfor anybody else because you
know everybody's money is theirown, but sometimes I think
(04:53):
priorities are just kind of outof line.
Dr Andrew Greenland (04:57):
And at what point did owning your own
practice become something youwanted to pursue?
Was there like a turning pointwhere you thought, actually,
this is this is this is thedirection I want to go in here?
Dr Mike Daniels (05:06):
Um, so when I was finishing school, you know,
uh finishing residency, youknow, 25 years ago at this
point, um, there were really twodifferent ways you went.
You either started a practiceor you went to work for a
practice.
And the idea being if youworked for a practice, you would
either eventually buy in as apartner or you would leave and
buy somebody else's practice andcontinue to go on.
(05:26):
Um, and that was the vastmajority of practitioners at
that time.
Um, the concept of employedphysicians with health systems
and multi-specialty groups andeven with orthopedic groups uh
really didn't exist in anysignificant manner.
You know, hospitals were nothiring podiatrists, those sort
of things back in the day.
Nowadays, as somebody who hirespodiatrists on a fairly regular
(05:48):
basis, um, people no longer arelooking for anything other than
a job.
And they will literally tellyou that.
Um, you know, they have zerointerest in anything
business-wise, they have zerointerest in ownership.
Uh, when I started hiringdoctors 20 years ago, I would
get asked all the time, arethere partnership opportunities?
I never get asked that anymore.
(06:08):
Um, and quite frankly, it whenI was a resident, all of my
attendings were private practiceguys, so I saw how they all
worked.
Nowadays, people are beingtrained by employed physicians
for groups, so they're still notgetting that whole practice
management experience.
Um, and due to the way some ofour you know contracts get
structured and the way healthsystems do, and due to the Stark
(06:28):
Law regulations, um, I thinkthe way they get compensated is
very, very poorly understood.
Um, and it really hurts thembecause they have a lack of
understanding.
Dr Andrew Greenland (06:38):
Thank you.
And so for you, was it um thewanting the clinical
independence or seeing abusiness opportunity or wanting
to do things differently, or allof the above?
Dr Mike Daniels (06:47):
Uh I think probably a little bit all of the
above.
Um, you know, I I just neverimagined doing anything other
than you know going intopractice and taking care of
patients.
Um, I remember, you know, earlyin my schooling, so my first
year at Temple University, um,looking at my clinical doctors,
the podiatrists who work at theschool, most of the clinical
(07:08):
first year is spent not withactual podiatrists, it's spent
with PhDs who you know haveexperience in physiology or
anatomy or whatnot.
So you don't get that quitethat much, but you do get a
little bit.
They have, you know, you have acouple of classes where
podiatrists come in and teach,you know, basic biomechanics and
those sort of things.
Um, and some of these guys werefull-time employed by the
college, and some of them were,you know, they came in, they
(07:30):
taught a class, they had aprivate practice.
Um, and I decided prettyquickly that I didn't think I
wanted to be a teacher.
Um, I didn't think uh, youknow, stay sitting in the
audience thinking about what Iwas thinking about the people
talking to me, I'm like, I don'twant people thinking that about
me.
So I said, this isn't for me.
Um, so I, you know, I just wentoff.
And I would ask a lot ofquestions to our part-time uh
(07:52):
faculty, you know, who hadpractices about what they're
doing and why they do it.
And, you know, most of them itwas very consistent for them,
and some of them had a love forteaching, um, you know, and some
of them had some other ulteriormotives that that you know
would come out every once in awhile.
Um, but I felt very differentlyabout you know being in a
employed clinical space where Iwas responsible for just you
(08:13):
know one thing and didn't have,I guess, creative freedom or the
ability to practice within myin my true scope of practice.
Um, you know, there was we hadbiomechanic attendings, we had
infection attendings, we hadsurgery attendings, you know,
everybody wanted to work withthe surgery attendings, nobody
wanted to work with anybodyelse.
And I figured, well, that's notgood either.
So I kind of just pursued thiswhole thing.
(08:34):
And as I went on, I wasfortunate.
My residency director was aprivate practice doc.
So, you know, and he would tryto teach us all kinds of things.
Uh, you know, I I talked to hima couple weeks ago.
I'm still very grateful for theopportunity he gave me.
And uh, you know, I just movedin that direction.
And then after I startedworking, uh, when I started to
see what I was generating, and Istarted to see, well, what
(08:55):
percentage of what I wasgenerating was I actually
getting in benefit, I startedscratching my head and going,
well, it makes more sense tohave a lot of people working for
you so you can take you knowpieces of everything than to
just try to do it all yourself.
Um, I I think every day I thinkthat might have been a mistake.
Uh, because sometimes I thinkmy life would be a lot easier if
it was just me.
Um, but the ability to be asingle solo practitioner doctor
(09:19):
in this in this day and age isso challenging because you're
just getting eaten alive withfixed costs.
Our reimbursement is notincreasing, it is declining both
in actual and inflationadjusted dollars.
And it just gets harder andharder to keep the lights on
every day.
So I don't know how the singlepractice guys are doing it.
And if you look at ourdemographic as podiatrists, most
of the podiatrists still insingle or just dual practice are
(09:41):
my age and older.
The younger guys aren't doingthat.
Very, very few.
And if they are, they'refinding a niche.
Um, you know, there's a wholeconcept of concierge pediatry,
which is trying to go, andthat's doctors who take no
insurance.
Some of them travel and go topeople's homes, some of them
have an office.
And, you know, everybody's kindof looking to find their place.
Uh, I'm too old to lookanymore, so I'm kind of stuck
(10:03):
where I am, and I think thisone's gonna ride this wave until
I grow until I retire.
But um it's it gets to be tothe point where you know you
have to kind of figure out, youknow, where does the money you
you make come from?
Because if you don't know whereit comes from, you don't know
how you get it, in which casemaybe you don't even appreciate
it.
And I think sometimes doctorshave lost the ability to
(10:25):
appreciate their patientsbecause of that.
I mean, listen, the systembeats the daylights out of you,
it really beats the humanity outof you.
So sometimes it's hard toremember that, you know, it
really has nothing to do withme.
It's all about the patient.
Dr Andrew Greenland (10:39):
Thank you.
So thinking about that timewhen you were you know wanting
to open your own practice, onething I'd realized in medicine
or any clinical training is thatwe don't get any business
training at all.
And I guess we're eitherworking it out from other people
around you who understand thebusiness side of medicine, or
you're kind of figuring it outon your own.
Which which camp were you in?
Dr Mike Daniels (10:58):
So I joined uh a gentleman in practice uh when
I first got out of residency.
Um he had been there for 25 orso years by himself, uh sitting
in a you know at the same officebasically.
And you know, I came in and Iwas, you know, all full of spit
and vinegar and wanting to savethe world one foot, one toe at a
time, or cure the world onesoul at a time, maybe.
Um and you know, I very, veryquickly realized that um he
(11:22):
didn't really do that much uh asfar as what patients' needs
were, what the services we couldoffer or could provide patients
were.
So, you know, two years intothis thing, I was making, I was
generating more revenue than hewas, and I was making more money
than he was.
So, you know, I foolishly tooka pay cut and became a partner.
And you know, that kind ofstarted my journey at that
(11:43):
point.
Um, and I really didn't see anyother way.
I explored the possibility ofbuying a practice, but I I had
you know somebody there who wasteaching me, you know, how to
practice.
It turns out a lot of it wasincorrect, which you hear a lot
of.
Um, people are just not toldthe right thing because a lot of
doctors, you know, after theages really, you know, flew by
(12:03):
the seat of their pants.
Um, if you go to lectures andyou you talk to older doctors
who are on the lecture circuittalking about practice
management aspects, they'll tellyou crazy stories about how
when they first got there andstarted in practice, there were
four codes, and they paid someyou know person $10 an hour just
to select the code.
And they figured, well, I coulddo that myself and save the
(12:24):
money, and you know, and alljust these crazy, crazy stories
about what it is.
And you know, as time has goneon and reimbursement has not
kept up with inflation and hasactually been cut, the
regulation and and uh andspecificity of medical records
for the purposes of billing hasjust gone crazy.
Um, here, for example, uh CMS'suh audit criteria is
(12:47):
perfection.
If you send a medical recordand it is not perfect, they will
do a clawback.
You know, it's no good try,it's no, okay, we understand the
patient needed the service,it's oh you did it.
It's no no no.
There are 27 things here, andyou only have 26 of them, so we
are clawing back the money,which is an impossible standard.
And they know it, and doctorsknow it, and that's why
(13:09):
everybody expects to have moneyclawed back, but they're already
paying us less for theseservices, and now they're taking
more back, and it's just anunsustainable model in that
regard.
So, going back to where thediscussion started is none of
that existed when I was startingout trying to figure this out.
Um, I don't know, I might havegiven up and gone to work at
McDonald's at that point becauseit's it's absolutely crazy.
(13:31):
I generally worry about thedoctors coming out of residency
and coming out of training now,what they're gonna do.
Because I mean, I neverimagined it could get to this.
So I can't even imagine whatthe next 20 years is gonna look
like.
Uh, it is a little bit scary.
So, you know, I think lookingat back at it, uh, I didn't
really know anything, and it wasprobably a good thing because I
(13:54):
think sometimes you can, youknow, know enough to be
dangerous.
Um, and I've just developedthis and I try to explain to our
younger doctors how thesethings are working, but
sometimes it's you know it'slike a deer in headlights, and
you know, every time I hear it,it's like, well, I don't have an
MBA.
I'm like, okay, well, I didn'thave an MBA when I started
either.
I couldn't answer any of thesequestions, that's why I got one.
And guess what?
An MBA taught me I reallydidn't know what I was doing.
(14:16):
That's all it really taught me.
So, you know, you just and andthe last thing I tell people is
I have probably made everysingle expensive mistake you can
make in podiatry along the way.
If there's a mistake that costsmoney, I've made it.
So you learn a lot from thelived experience as well.
So, you know, I have justmatured into this position.
(14:37):
I don't think this was ever anactual goal.
I don't think I'm ever going toarrive at, you know, the end at
the end of the road saying, Igot there.
I think my road's just gonnaend one day, and I'm gonna say,
okay, and you know, do what allpeople do and retire and move to
Florida.
Dr Andrew Greenland (14:52):
Thank you.
Really great insight.
So you just mentioned the MBAin talking.
I'm just curious to know whatdid it do for you and how has it
helped you over the years?
Dr Mike Daniels (15:01):
Um, the best way I can explain it is my MBA
program was more like a foreignlanguage degree.
Um, the the language ofbusiness and the language of
finance is very, very differentthan the language of medicine.
And you you get into a group ofdoctors who are generally the
smartest people in the room, andthey start talking to people
(15:23):
who now run hospitals.
Now, when I was training andwhen I was early in my career,
most of the hospitals were runby doctors.
Most of the C-suite weredoctors.
Now you have one doctor in theC-suite, and nobody else there
has any medical degrees.
It's all business guys.
Um, and when I was, I don'tknow, about five or six years
old or so, I started serving onthe perioperative governance
committee for the hospital.
(15:44):
And that would be a committee,there would be admins there,
there would be representativesfrom the different specialties
there.
And I remember sitting in thatclass and sitting in that
meeting, and people who reallyhad no animosity towards each
other were screaming at eachother because they weren't even
talking about the same thing.
And and when I got the languageskills from my MBA to realize
(16:05):
what the business people weresaying and why the I knew why
the doctor people didn'tunderstand, it was like an
epiphany for me.
So now, whenever I'm in thosethings and I I sit there and I
laugh because I love how youknow the they'll come, the the
admins will come in and say,Well, the hospital did better.
We only lost four milliondollars last year.
And then you look on the andthen you look on the PL and
(16:26):
there's you know $17 millionworth of depreciation.
Like, well, you don't lose fourmillion dollars because you
didn't spend that money.
And like everybody's like, oh,well, the hospital's losing
money, we're gonna go bankrupt.
No, it's paper loss, and theydon't understand.
And the business people eitherdon't understand that the
doctors don't understand or arehappy with them being
(16:46):
uninformed.
I don't I never know which oneit is.
But it's just it's learningthose language skills to be able
to actually sit there andunderstand what's going on when
people tell you stuff, andbasically to understand when
you're being lied to.
Dr Andrew Greenland (17:00):
So is the MBA something you pursued
because of problems you'reencountering in the practice, or
had you always wanted a formalbusiness as education to kind of
cement what you were doing?
Dr Mike Daniels (17:10):
Um so I was an economics minor in college,
which taught me absolutelynothing about business.
Um, but you know, if you wantto talk about you know supply
and demand or laugh at hercurves, I'm your guy.
Um, so but I I the funny thingis, I was talking about this the
other day with with acolleague, is um I loved my
economics classes.
Everything just made completesense to me.
(17:31):
I really didn't have to studyfor them.
All I had to do was learn thevocabulary, and it was easy
because you know, I mean,listen, everything actually
comes from supply and demand,and then you just break off.
Uh, it's kind of it's kind oflike physics uh with Einstein's
theory of relativity.
Everything starts with that andthen breaks off, and you start
breaking the components downinto their other components.
You can do exactly the samething in these circumstances.
(17:52):
So when I started running thepractice myself, when I bought
out my original partner, um, andI told people when I got to my
first you know million dollarsof revenue year, and I was
thinking I was the greatestthing since sliced bread, um, I
began to realize in talking,especially my accountants, that
I had no idea what that meant.
And I had no idea where ourdollars were going, and I had no
(18:12):
idea how much taxes I was goingto owe.
I didn't understand any of it.
And I would go to meetings withmy accountant, and the
accountants would just starttalking, and I was they might
have been, I always say theywere like the teachers from the
comics, uh, the comic peanuts.
Charlie Brown and Peanuts arevery familiar with that.
Well, every time they had acartoon of that, and they had
the teacher, the teacher wasjust a trombone going, wah, wah,
(18:34):
wah, wah, wah.
And that's what the accountantsounded like to me at that
point.
So, you know, I was able to dothis, and then, you know, last
year, the year before, I'msitting in a meeting with our
accountants, and I said, youknow, oh, we need to put this on
the balance sheet because thisis a single-time use and it's an
abnormal thing, and it's notreally an expense.
And the junior accountant'slike, no, no, no, you paid it as
(18:55):
an expense.
And then the senior accountantsaid, No, no, we can do that, we
can move that over.
And part of it was because Iwas trying to, you know,
increase valuation uh by youknow increasing profits by
moving costs off the PL.
Um, but again, I knew to dothat, and the the younger
accountant didn't quite get it.
So it's kind of one of thesethings where uh I'm glad I did
it.
I actually did enjoy businessschool.
(19:17):
Uh I was I did a cohort, so Iwas basically it was all done at
home.
Um, I would just sit there andwrite, and I would come home
every day from work, and fromlike seven to nine, I would sit
there and I would write, andthen I'd spend you know four or
five hours on each day duringthe weekend, and I would just
sit there and write.
And you know, I got through it.
Um, and I actually didn'tstruggle at all.
I really enjoyed it.
And I'm still kind of toyingsomeday with the idea of maybe
(19:39):
going back in uh my health, myMBA's in healthcare
administration, maybe getting aconcentration with finance, um,
because I'm a glutton forpunishment, I guess.
I don't know, but um, I stilldon't think I completely
understand corporate finance, atleast understand it enough to
really and I would like to learnmore.
But I'm also from thegeneration where if you didn't
understand something, you wentto the library and got a book.
(19:59):
You know, you didn't whip yourphone out and have you know
Google tell you in 12 seconds.
So um that's why I went back toschool because that was me
getting a book.
It was me getting the educationthat I would have had to Google
and try to figure out andwouldn't be able to comprehend.
Dr Andrew Greenland (20:14):
Okay.
So in your evolution then, whendid your thinking start moving
from I own a practice to I couldactually build an organization
here?
Dr Mike Daniels (20:23):
Uh that just mature by itself, too.
Um, when I was first inpractice, um the idea of
in-office surgical suites wasreally kind of coming into its
own.
Um, and back then the surgicalsuites were really well
compensated.
And I said to myself, well, whyam I giving all this money to
the hospital surgery center whenwe can just have our own?
So that evolved.
(20:44):
There was already durablemedical equipment when I got
there.
We were already doing diabeticshoes and cam boots and some
braces and those sort of things.
Um, so that aspect was there,but you know, we've now expanded
that to wound supplies andcompression garments and things
along those lines.
Um, and then you know, we'vestarted a clinical trials arm.
Um that's a revenue generatorand a patient generator as well.
(21:05):
Um, part of it is because wetake projects that we're
interested in, and secondarilyis you know, it helps to you
know put our brand out there forthat.
Um, and then along the way, andagain, this is around 2010, um,
we were really unhappy withwhere our billing companies
were.
So uh a friend of mine and Istarted our own billing company,
(21:26):
and we started with twoclients, his practice and my
practice.
And we grew it and we had abouta dozen clients at one point.
Um, but it actually started towind down.
And when we moved out of theour our private market, where we
just basically practice into amedical services organization,
we folded the medical billingcompany and rolled it into the
medical service organization andgot rid of the last of our
(21:47):
clients.
So now the only billing clientwe have is us, um, which has
made life a little bit easierfor us.
But it's that whole kind ofprogression of just adding
services that I talk about now,I consider them service line.
Where back then I didn't knowwhat a service line was from a
you know from a bus stop.
Um so as we got these servicelines added and we started to
(22:08):
look at added value for thesethings, that's kind of the
progression that we go.
So to fight insurance declinein reimbursement, we look to
figure out is what are ourpatients getting that we're not
providing and what can weprovide them?
So we get the dollars.
I mean, they're spending itanyway.
We're not looking to havepeople spend more money than
necessary.
But if you're already gettingit and you're going to XYZ
(22:31):
distributor, and I can do it inmy office and you know have some
profitability with it, well,that's what I want to do.
And that's where this wholething blew out of is it's okay,
what can we add now thatgenerates revenue to displace
the decline that we're seeingand to provide better service
for patients because it's awin-win for us.
And you know, to this day,there are lots of practices that
(22:52):
don't do a whole bunch of thosethings.
I think they're really missingout.
One is they're missing out onrevenue sources, but number two
is when you give somebody aprescription and send them out
the door, they are far morelikely to lose it and not do it
than you are when you give themthe product in the office.
So compliance goes up, sosatisfaction goes up, and all of
that is super important thesedays because people go on Google
(23:15):
and rank you now.
Uh, you know, and you know, ifeverybody's, you know, if if if
you know somebody says, Oh, youknow, my doctor got me my
diabetic shoes, and I was like,Well, well, I had to go to this
pharmacy and they didn't fitright, and you can see the
difference.
So, aside from being revenuegeneration now, it's also
practice promoting.
And, you know, anything that wecan do that promotes the
(23:36):
practice for free or promotesthe practice where we get paid
to do it, like clinical trials,we're all for that and we take
advantage of that.
Dr Andrew Greenland (23:45):
Thank you.
And is it um which is thebiggest leap?
Is it from one practice to thesecond office, or is there
somewhere else further down theline where it becomes the
biggest challenge for you fordoing this?
Dr Mike Daniels (23:55):
The biggest challenge is just the concept of
expansion and whether or notyou're going to do it through
acquisition or de novodevelopment.
Um, I personally am a bigbeliever in acquisition.
Um, you know, it's nice to buya revenue source, it's nice to
buy an office where everything'salready equipped and you just
have to update, as opposed toyou know, going into a blank
(24:16):
space and imagining what itcould be and building something.
Um, again, you can tell whatsomebody did, and you know,
statistically we always talkabout it.
You buy a practice, 10% of thepopulation walks out the day you
walk in because they're onlycoming to see the other doctor,
and it's not convenient forthem, so they're going to go
somewhere that's convenient ifthey can't see the same doctor
they're soon.
(24:37):
Um, so I but again, and Iaccount for that whenever we do
an acquisition, but I thinkthat's better because you have a
revenue source and you canactually put together a budget
for that and figure out whetheror not you can improve that.
And again, a lot of that isgoing back to adding ancillaries
to improve revenue.
But um, when you start cold,uh, unless it's an area with a
(24:59):
huge demand, you know, it's likeany business that you're
starting.
And you know, if you want tocompete against the neighbor, I
mean there's nothing wrong withthat, but is that always the
best medicine?
Um, and and I personally don'tthink so in most circumstances.
So, you know, I think the theconcept of just I think
everybody wants to be biggeruntil they figure out what that
really means.
(25:19):
But when you decide to getbigger, do you do it by
acquisition?
Uh, do you do it by de novo, orcan you expand your current
practice beyond what's currentlybeing done?
Uh, because if you talk toanybody, most people will tell
you that they're maxed anyway.
Nobody ever seems to have youknow extra room.
Uh, you know, nobody has someextra time there to throw in and
do it.
And everybody's just you knowcrazed.
(25:40):
And we had this exact thinghappen in our office this week.
We have added a balance andfall prevention program to our
practice.
Um, and you know, to make sureit takes the medical assistant
about a minute to just run thepatients get an iPad basically
and they fill out, you know, Ithink half a dozen questions,
not a big deal.
The medical assistants spendyou know about a minute doing
(26:01):
you know, balance testing, andthen we come in and we review
all the results and we discussthem with the patient and you
know put together treatmentplans to prevent falls.
Um it's actually a CDC and CMSpromoted program.
Um, our admins in our practicewere freaking out because nobody
has time to do anything, andthis is gonna add so much time.
I asked the medical assistantthat works with me regularly,
(26:23):
I'm like, what's going on here?
Is this hard?
He goes, No, it takes me lessthan a minute.
So if you're a minute and we'readding revenue, we're gonna
prevent falls, which is gonnahelp our patients, and our
admins are freaking out about itand saying, Well, it's not
enough.
I'm like, Well, I'm sorry, it'shard to find enough.
And if you ever do, please letme know because I haven't.
What we're trying to do is keepthe doors open, and this is one
(26:44):
more way that we can helppeople and keep the doors open
at the same time.
So it's those decisions becauseinevitably nobody likes change,
and it doesn't matter how goodthe change is, the first
reaction is usually negative.
Oh, we don't want change,change is bad.
Change means more work, changechange means more complaints,
more issues.
Yes, but again, change is alsohow you grow.
(27:06):
You can't grow without change.
And yeah, and I know gettingthe expansion bug, those are the
sort of things you need to lookat.
Which one of those three?
And if you do that and you canmake a decision and you can be
happy with your decision, thensometimes you're a better man
than me.
Dr Andrew Greenland (27:22):
So bring us up to date with where you are
now.
What does um we treat feet looklike today compared to that
first practice?
Dr Mike Daniels (27:29):
Uh so we are now uh, you know, as we say,
we're now a platform, that's whywe turned into a medical
services organization.
So we actually now have anownership structure where we
have a non-physician owner.
Um, and there's corporatepractice and medicine laws and
things like that that are wellbeyond my understanding or my
pay grade uh to make it legal.
But that's the way it has tobe.
So, you know, we have theability to compensate our you
(27:53):
know really good employees andturn them into owners, um, which
is a big change from where itis.
And you know, I came in and Ipaid, you know, I wanted half
the practice, so I paid you knowhalf a year's gross, um, which
nowadays is insane to thinkabout given what cost runs are
for practices.
Um, so you know, we can dothat.
Um, it allows us to give equitypieces to physician in our uh
(28:16):
area um without having them goout and borrow a million dollars
to buy 20% or whatever.
So uh we can do it to themwithout with adding significant
structured debt through a coupleof different ways that we go
about doing that.
So, you know, breaking it downand then breaking it down into
different service lines, and youknow, you can't do every
service line in every office,but what are the crucial or the
(28:38):
essential ones that have to belocated there?
Um, and then there's just theshifting demographic of medicine
in general, with you know,higher deductibles and higher
copays and those sort of things,which start to limit treatment
options for patients, um, youknow, which is hard.
I mean, if you thinksomething's better for patient
and they can't afford it, um,what are you gonna do?
And we we had those decisionsbefore, but not like we do
(29:00):
today.
So those things all combinedtogether have now allowed us to
do that, have allowed us to getto our current state.
And the idea being um, youknow, two offices cost as much,
cost more than one office, buttwo offices don't cost as much
as two one offices.
And then three offices costmore, but they don't cost as
much as two two offices, and itjust grows from there.
(29:22):
So by doing economies of scaleand reducing your overhead
burden, um, that's the way tocontinue to grow.
And and again, you know, um asphysicians, we're not exactly a
sympathetic group when it comesto you know earnings.
Uh, people are not reallyworried about their doctor not
being able to eat dinnertomorrow night because their the
(29:43):
reimbursement declined.
So if you're gonna figure outhow to be able to run the place
and you're gonna figure out howto be able to maintain
everything where every year therent goes up and every year the
employees need raises, and everyyear health insurance goes up,
and you know, malpractice goesup every year, um, you have to
figure out how you're going todo that.
Because the previous answer wasjust see more patients.
(30:04):
Well, I'll tell you, therearen't enough hours in the day
for me to see more patientsanymore.
So I got to figure it outsomewhere else.
And that's kind of you knowwhere we've moved it into, and
that's the biggest differencenow.
Because again, I got out, Ifigured I could see everybody in
the world, I can see 100patients a day, and I'd be fine.
Well, no, I can't.
I'm too old for that now.
I don't move that quickly.
Um, but even so, I you know,when you see too many patients,
(30:25):
the care you provide starts tosuffer, and that's unacceptable
to me too.
So we try to make sure thatwe're doing everything we can to
keep the lights on while stillproviding the highest level of
care that we can.
Because if you start tocompromise care, then you you
might as well go out of businessbecause you've done.
Dr Andrew Greenland (30:42):
And there's a follow-up to that, and you
may have partially alreadyanswered this, so forgive me.
But why is the overhead ofrunning an insurance-based
medical practice in the US sohigh?
Obviously, I'm in the UK, so Idon't have this understanding of
the model quite so much.
And also, what are people doingwrong that are not making it
work?
Dr Mike Daniels (31:00):
Uh, quite frankly, I'll tell you, I don't
think there are people whoaren't making it work because
they're doing it wrong.
I think the people who aredoing it wrong are just getting
in trouble down the road.
Uh, because people don't tendto be under, they tend to be
over.
Um, it I joke about this allthe time.
It's like sometimes I think,well, maybe if I just charged
every patient 50 bucks wheneverthey walked in the door and took
no insurance, I would be betteroff because first we have forms
(31:23):
that have to be filled out andinsurance forms that have to be
copied and have to be scanned.
Then I have to see the patient,do a note, and then figure out
what I did and how that relatesto the billing codes that I
choose.
Those then go from you know,from our section in the
electronic health record to thebilling section, and they then
have to review it, make surethat everything from their
address, phone number, date ofbirth, and all the coding is
(31:45):
correct.
Uh, they're looking formodifiers and other things, I
see different ICD tens, becauseyou can have two ICD tens that
say the same thing, but one ispaid and one isn't.
If you don't have the rightdiagnosis, it won't get paid, so
they have to scrub those.
So we then send those to aclearinghouse.
A clearing house, I don't know,even know, other than being a
middleman and exchanging money,I'm not really sure what they
do.
(32:05):
But they then process it andsend it to the third party
payers, and the third partypayers, you know, then decide to
pay us or decide not to pay us,and that's where it gets to be
expensive.
So every single step you havecosts you money.
So, and there is zero way toeliminate any of that because
I've done everything I can totry to.
(32:26):
Um, at the end of the day, canI streamline some of them?
Yes.
Is technology and AI helping?
Yes, but every single stepcosts money.
So think of it this way the thecare you provide the patient is
only one part of a very longchain, and that's why everything
in the US costs so much,because everybody has their hand
(32:47):
in the line and everybody getspaid along the way.
Um, and then you know, talkingabout billing and that with a
lot of doctors is you knowcommitting blasphemy.
So, you know, dirty money is adirty word in medicine.
So, you know, nobody reallywants to take the time to figure
that out, and that's reallywhere the problem is.
Dr Andrew Greenland (33:06):
Yeah, when we first connected, I think you
said one of the biggestoperational challenges was
phones.
Tell us what's happening there.
Dr Mike Daniels (33:13):
I'm sorry.
Dr Andrew Greenland (33:14):
I think when we first connected, you
said one of the biggestoperational challenges was
phones.
So can you sort of tell us alittle bit more about where
what's what's the problem there?
Dr Mike Daniels (33:23):
Well, I think I think it's way too easy to get
bogged down in um in the patientcare aspect and realize that at
the end of the day, if youcan't keep the lights on, you
can't help patients.
So, you know, the focus isalways on the patient.
We're all taught to do that, weall do that.
I mean, it's almost just uh gutreactions at this point, and we
(33:44):
know nothing else to do.
But again, sometimes you'remissing the bigger picture, and
that's that's really what'sgoing on.
So uh you really need to stay,you know, focused on the medical
part, and then either youbetter have somebody like me who
can focus on the business partto make sure everything drives,
or you're gonna end up introuble.
And I think that's primarilywhat I mean by focus.
Dr Andrew Greenland (34:09):
So, with all your business experience and
where you are in your umprofessional journey, what are
the things that still keep youup at night in running this
show?
Dr Mike Daniels (34:18):
So I, you know, again, there there are a
handful of things that do.
Uh, you know, obviously, isthere enough money this week to
make payroll is always on mymind.
Um, you know, I I I tend towork now in you know short,
maybe you know, three to fiveday blocks of revenue generation
because we have to make surethat we can pay all our bills so
that keeps me up at night.
Uh patients who aren't doingwell still keep me up at night.
(34:40):
Um, it doesn't matter if I hadanything to do with it or not.
You know, I will lie there andthink about what else we can do
differently, do differently forpeople.
Um, you know, and then again inthe US, you know it's a very
litigious society.
So, you know, I sit at dinnerwith the TV on and there's 17
doctor, 17 lawyer commercialsscreaming, did your doctor make
a medical mistake?
Call me, I'll get you justice.
(35:01):
I don't know how justice becamea synonym for money, uh, but
somewhere along the line it didhere.
So those are the sort of thingsthat keep me up.
That and then staffing issues,and it doesn't matter, physician
staffing issues are always anissue, and support staff issues
are always an issue.
Um, it seems like we never haveenough of either.
Um, and doctors hanging ashingle and sitting in an office
(35:22):
for 30 years is is over.
There's a ton of mobility inpeople's careers now in
medicine.
And uh I've had people tell usthat you know, our initial
contract offer, so somebodycoming out of residency, we're
gonna offer them a three-yearcontract.
Well, three years is too longbecause I'm not sure I want to
stay there for three years.
What you have a hundred, youknow, you're $500,000 in debt
(35:42):
and you don't want a guaranteedjob for three years?
That doesn't make any sense tome.
So, you know, the grass isgreener somewhere else, I guess.
Um, but it shocks me thatpeople are now just blatant
about the fact that they don'tintend to spend their career
there.
And you know, you're you you'rea doctor, you've gone to the
doctor.
People like to go to the samedoctor, they they like to get
(36:05):
that comfort level, especiallyin a profession like ours, where
we do have patients thatreceive four to five times a
year, every year for years.
Um, you know, I I assume it'ssimilar in primary care where
you know you're seeing thepatients whatever the protocol
is for whatever their conditionsare.
Um, but again, I hear from mypatients when their intern is
move on and they can't find youprimary care doctors or they
(36:26):
don't like the new one and hadthe old one for so long, and
those sort of things.
So I I worry about how to makesure that we're maintaining the
same kind of um practiceintegrity, I guess, that people
grew up relying on because it'sreally not there anymore.
Dr Andrew Greenland (36:45):
So if I gave you a magic wand, then you
could fix anything in thebusiness overnight.
What would that be?
Dr Mike Daniels (36:50):
Oh, I I would just double our revenue.
I think that would uh solve allof my problems.
Uh if I could just double myrevenue overnight, um, that that
would be nice.
Uh, you know, and other thanthat, it's things that come up
as time goes on.
Um, we're here in Maryland acouple of years ago, there was
uh a big cargo ship that ran andliterally knocked one of our
major bridges into the water.
(37:11):
You may have heard about it.
Um and we had three officeswithin 15 miles of that bridge,
and everything just stoppedbecause people couldn't get
anywhere because they couldn'tget to the other side of you
know we call it of the bay.
And uh, you know, our revenuewithin the first three months
after that in those threeoffices dropped like 70%.
(37:32):
It was crazy.
And of course, now people kindof figure out how to do things
and those sort of things.
But in the beginning, it wasall very much um uh that you
know, people couldn't figure itout.
So we had doctors just sittingthere.
Dr Andrew Greenland (37:47):
You've had a pretty long, successful
career.
Um, if you were to have yourtime again tomorrow, would you
do anything differently?
Dr Mike Daniels (37:54):
Yes.
When I graduated from college,I would have gone to work in the
mailroom at Goldman Sachs andworked my way up.
I would have worked less andmade more and probably been
retired by now.
Um, you know, you hear allthese Wall Street the crazy
hours.
And if you talk to privateequity guys, the crazy hours
they make their juniorassociates work.
And I'm like, well, that's justThursday.
I don't know what you'recomplaining about.
(38:14):
You know, oh well, we getemails at 11 o'clock at night.
I'm like, we get calls at 11o'clock at night.
I have to leave and go to thehospital.
So I always say, yeah, Iprobably would, if I had half a
brain in my head, I probablywouldn't do this, despite the
fact that I'm not sure whatthey're doing all day that's
taking them so long.
They're looking atspreadsheets.
I don't know what people didbefore spreadsheets, but uh I
don't know.
But it seems like uh thatprobably would be a better way.
(38:36):
Maybe I'd be sitting in theHamptons town instead of uh here
in Maryland.
Dr Andrew Greenland (38:40):
But on a serious note, if you uh having
your time again and you werewithin you were staying within
this career, would you doanything differently um from
this career perspective?
Dr Mike Daniels (38:50):
Um I I might have looked a little bit um a
little bit more at maybe doinggoing the allopathic career
route.
Um, you know, I I I have thiskind of administration thing,
and I in the back of my mind Ialways think, well, I could run
this hospital better than thoseguys.
So, you know, but I I don'thave the background to do it.
So um I I don't know.
(39:10):
That could have been something,but uh at this point, no, not
really.
Um I'm not I don't have anyregrets about choosing to be a
podiatrist, uh you know, maybebeing a doctor in general, but I
honestly don't think it wouldbe any different if I was a
dermatologist.
Dr Andrew Greenland (39:26):
And what are the future?
Where is um WeTreat Feet goingto be in the next 12 months or
so?
Do you have any plans for thebusiness and plans for what you
want to do with it?
Dr Mike Daniels (39:34):
Well, I mean, again, uh, you know, I'm much
closer to the end of my careerthan the beginning of my career.
So, you know, I'm you knowshaping out my my exit strategy,
and there's no me to come byme.
So, you know, one of a coupleof things is gonna have to
happen.
You know, one is I'm gonna haveto you know become a part of a
larger group, whether that beyou know through purchase of
(39:54):
equity and you know, being uh uha tuck-in, or whether that you
know being a format, uh platformformat for a company, maybe
that way.
Um, you know, do we startselling off pieces and you know,
we buy this piece and you takethat piece and that?
Um, you know, do I just youknow close the door, turn off
(40:14):
the lights and say buy one day?
So, you know, those are thesort of things they're growing.
I think realistically, based onthe market, is we'll get
acquired by somebody much, muchlarger than us one.
There's a about a half a dozento a dozen uh companies now
acquiring podiatry practices andand you know forming these
large groups, two or three andfour hundred doctors.
And I think at some point we'llget we'll get gobbled up by
(40:36):
them.
Um, not really sure what thatwill mean for me.
Uh, you know, would I just goback to being a regular plain
old doctor coming in at you know8:30 and leaving it for?
I don't know, maybe I would.
Would I then start to you knowrise in administration and and
rise in the corporate structurethere?
Maybe I would.
Maybe it's too late to do that.
I I don't know.
Um, you know, needs to say, Iyou know, I'm not 100% sure what
(40:57):
I'm gonna do on Monday yet.
So I don't know if I can thinkabout 12 months down the road.
But uh again, at the end of theday, um I am starting to really
seriously think about my exitstrategy because they say you
got to do that at you know, youknow, three to five years ahead
of time.
So, you know, I'm thinking I'mgonna be around another eight or
ten years.
I really need to put somethingin place.
Dr Andrew Greenland (41:18):
Mike, with that, I'd love to thank you so
much for joining us today.
I've really enjoyed theconversation.
I really uh um what I wouldparticularly appreciate is your
perspective that you're lookingat healthcare from both sides.
So the responsibility of beinga physician, but also delivering
good patient care.
And it's been so interestinghearing you know how you've
built and scaled your businessand your perspectives on running
it from where you stand.
(41:39):
So it's been a greatconversation.
Thank you very much indeed fortalking to me today.
Dr Mike Daniels (41:44):
Thank you for having me.
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