Interview with Dr. Alberto Panero - BIOS Orthopedic Institute

Dr. Pinero, a board-certified physical medicine and rehab specialist, has founded the groundbreaking BIOS Orthopedic Institute in Sacramento, California. Driven by a vision to revolutionize sports industries and provide top-notch care, he shares the ups and downs of his incredible journey.

Tune in to this insightful episode packed with valuable business knowledge and orthopedic expertise. Elevate your understanding of orthobiologics and sports medicine!

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Transcript

Intro

Hey, I'm Dr. Ariana De Mers. I'm an Orthopedic Sports Medicine Surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective, but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for help. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on the value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.

Dr. Ariana

Hi and welcome. This is "The Business of Orthobiologics" podcast. And today we have Dr. Alberto Pinero. Dr. Pinero is a board-certified physical medicine and rehab specialist with a subspecialty certification in sports medicine. He is the founder of the BIOS Orthopedic Institute where he practices in Sacramento, California. He is also a core faculty for the University of California, Davis, Physical Medicine Rehab Sports Medicine Fellowship. He is regarded as one of the experts in orthobiologics and musculoskeletal ultrasound and has published several papers on the topics. He has also presented research and interventional orthobiologic techniques at top orthopedic and sports medicine conferences. He's also highly involved in the sports community, serving as a team physician for the Sacramento River Cats, a Triple-A affiliate of the San Francisco Giants, and the A-team physician at Sacramento Republic FC. So, welcome. Thank you so much. This has been great. And I am so excited to have you on our podcast. I wanted to know if you could start from the beginning. You know, after training, where did you start? I know you didn't just start at BIOS. Where did you start and how did you get to where you are now with BIOS?

Dr. Panero

Sure. Well, first of all, thank you for having me. It's a pleasure to be here and share my experience more so on the business side of things, which I do enjoy just as much as practice in medicine. I think it started with division, right, and, you know, going back to why I became a physician in the first place. You know, I had my own sports injuries, which I felt like didn't necessarily get the best care you know, at the time, looking back on it. And I wanted to be able to provide opportunities, especially for younger athletes or those who didn't have access to high-level medicine, to really be able to get back on the field, right? So that was the vision. And I think I always had you know, kind of this idea where I wanted to have my own sports clinic and I wanted to be able to build you know, if you build it, they will come type of scenario. Little did I know it's not so easy where you just build it and they come, and here I am ten years into it. And it's been a journey, certainly, a good one, but hopefully, people can learn from some of the things I've done. I think where I benefited or, you know, kind of right place, right time, I finished at UC Davis, my fellowship, and there was a physician who was leaving. She was a full-time physician at the time, and they needed someone to kind of fill in a spot at UC Davis. And then on the other side, one of my fellowship mentors who was in private practice who I had a really good relationship with. He was like, hey, you know, why don't you come and start your practice here and we can work together. And thankfully, I was able to find a way where I was able to do both at the same time without interfering. And that allowed me to open up my own practice while still having kind of a part-time academic job you know, that paid the bills and gave me a lot of really good experience. And then from there, you know you start to work. I was working in private practice with five orthopedic surgeons, which was great. It was a great experience for me. But being like the non-operative guy or the interventional guy in the group, I just ran out of space there where I felt like in order to serve my patients better, I needed to have a fluoroscopy unit, kind of a bigger space. I wanted to build an orthobiologics lab. And that's what led to this idea of building BIOS to be able to really help more people and be able to do more of the things I wanted to do and have the autonomy to do it. So I guess that's the short kind of pathway on how I got to BIOS.

Dr. Ariana

Yeah. How many years have you been open with BIOS now? So you started in private practice, kind of half-time academic, half-time with private practice, and then now you are full-time at BIOS. And how many years have you been there?

Dr. Panero

Yeah. So we started the private practice in 2014, which was officially called BIOS. And then I want to say I did the part-time thing for about three years. And then by 2016, 2017, I was in full-time private practice. And then that took another several years to get the new space found and built out. And obviously, Covid happened. So I've been open at BIOS for about a year and a half now.

Dr. Ariana

Awesome.

Dr. Panero

In total, I finished my fellowship at the end of 2014, so to give you an idea, nine years, I guess.

Dr. Ariana

Okay. Now, how did you know how to do this? How did you know how to open a business and what kind of made you confident to take that big step? I mean, building out a space and going into it. And you are solo, or maybe we'll get into that a little bit later. But how did you know how to do this? Do you have business training or-- kind of share with everybody what your knowledge base going in was?

Dr. Panero

Well, I would say my knowledge base at the beginning was more just ignorance is bliss and thinking that I knew more about business than I did. And I just said, well, I really want to be able to do this. So I just started looking, okay, what are the steps, right? And the first step was to get in a professional corporation. So I had to find an attorney and, you know, I was able to get incorporated. That was step one. Step two was actually to get contracted with Medicare and get contracted with all the different private insurances. And then step three is really being able to find a way to get into your local HMOs, which, you know, I found that the hardest part. You know, getting Medicare, getting PPOs on those panels. Obviously, it's not easy to negotiate a great contract, but you can get contracted with them. But some of the HMOs in town, those are tougher [inaudible] 

Dr. Ariana

I think we had maybe a little pause, but let's talk about-- so you are contracted with all of the insurances, but you do quite a bit of orthobiologic treatments. How do you integrate that where some of your clients are insurance-based and some of your clients are cash-based? And maybe share how much percentage-wise, what are we looking at for you.

Dr. Panero

Yeah. So we do about 50% cash pay, and then the rest is divided into you know, Medicare and private insurances. I think what's important is understanding your contract and understanding the rules, right? For instance, with Medicare patients, making sure that they sign an ABN if you're going to do a cash pay procedure for them, with your private networks, understanding how to get prior authorization and making sure that you go through the proper steps before doing a procedure that's not covered by insurance. And it can be a little bit challenging to navigate that, and you just have to go through the steps. I think for me is obviously offering my patients options. Right? And from the first visit, I say, hey, these are all your options. These are the ones that are going to be covered by insurance. These are the ones that are unlikely to be covered by insurance. And I give them the pros and cons and kind of the benefits of each. And then they get to decide which way they want to go. And I always say it's not a right or wrong answer. It's really what fits more with where you're at with the process, with what you've tried in the past. You know, If you haven't tried anything, then okay, we can maybe go through some of the traditional stuff versus where you know, I'm seeing things now that I feel like orthobiologics have such a good role in that I might say, hey, we can try that, but I think this may be better because of A, B, and C. Right? I think it's just having honest and open communication with the patient about it.

Dr. Ariana

Got you. Can you share a little bit about how your office is set up? Are you sole or do you have partners? Can you share a little bit about how the structure for your offices?

Dr. Panero

Yeah. So we have, I guess it's private practice. We have a physician assistant and we also have a part-time physician. Basically, you know, we've gotten to the point where it's just a really good flow where we all kind of practice under the same methodology. You know we make sure to kind of have the right, I guess, culture within the workplace about what we're trying to communicate to the patient. So that way, no matter who they see, they're still getting the BIOS experience. It's not just them seeing Dr. Moore, they're seeing Dr. Panero. Even if our physician assistant, who's great, is having a conversation, we're going to be relaying the same messages. And then also having a really open communication, right, where, hey, if someone needs to run a case by somebody, we're always there. Right? Or, if someone needs to pop into a room, we're always there. Then also is the support staff. We have a great support staff. We have an amazing clinical director. Her name is Sabrina, who basically runs the whole office and makes sure everything is going smoothly. We have an MA who's also a phlebotomist, which I feel like has helped a lot in expediting the-- especially the PRP procedures, especially if you're going to have a lab, right. And you're on the cell counter and you have all these things, you need you know dedicated staff. You don't want to be trying to do that all yourself. And then it's back office, running referrals, getting people in, you know, making sure that the customer service is really good. I think that's big for small private practices is where we can really gain is making sure that that person really feels like they're a unique individual and the customer service is on point, which you may not get at the larger centers where you know, you're going to call and call, you're going to get the run-around, it's going to take you three to four months to get in, right? Those are the things that we're trying to make up ground for.

Dr. Ariana

Absolutely. Now, what do you think has been your most important business decision that's been a game-changer for you?

Dr. Panero

That's a good-- there are probably a few, right?

Dr. Ariana

Yeah.

Dr. Panero

Well, I think number one is I think the decision to pick what you want to be, right? So when I came out, I had a really big interest in sports concussions. Right? I wanted to be the concussion guy. I loved sports science and performance, right, and I wanted to do all these projects with the teams I covered with sports science. I loved orthobiologics, and I wanted to be the orthobiologics guy. Then, you know, you want to be also the guy that can do the medical side, at least in the non-operative side, right, like the compartment syndrome, exercise-induced asthma, these things. And I realized that there was just no way, I was going to be able to be the guy at all those things. Right? And I think I had to, kind of slowly start to focus, and I really ended up becoming the orthobiologics guy. It's not that I still don't see the other things, but I feel like you kind of have to decide where you want to be and what you want to be really good at. Two is I think not caring about what other people how they're doing it, or if they're telling you if there's someone else in your practice, you really, I think, have to pick how you want to run your practice, how you want your practice flow to go. You want to really be able to bring in the people that are going to work with you and train them. And that means being involved in the hiring process, right? Where you can really be one-on-one with that person and can I really work with this person? And then from there, I think is going out to the community and really being you know, impactful, right, where you're going and doing seminars, you're going to the physical therapy offices, you're going and meeting with primary care offices. That was a really good business decision where we really built a good network within the community. And then lastly, I think is knowing your numbers, right? Just from a business perspective, right, like Marcus Lemonis says, "If you don't know your numbers, you don't know your business", right? So you have to find a way to really become dedicated to the business side of it, where you're really understanding what's coming in, what's coming out, where is it coming from, right, looking at the people who are sending you referrals and really giving back to them, not in a kickback way, but in a way of service, right, where you're providing a great service for their patient. And then also identifying areas that, hey, maybe I'm not getting referrals you know, from A, B, and C, what can I do to maybe get my name out there, do some education where we can get more referrals that way? And then lastly, I think is once you're ready for it you know, building BIOS was the complete game-changer, you know. It was the dream come true. Having the facility that I wanted with, you know, all the little intricacies and all the little things behind-the-scene that people don't see that make that flow and that process go really well. And it has really elevated our service in the way that we can help people.

Dr. Ariana

Awesome. So what kind of--

Dr. Panero

Was that too long of an answer?

Dr. Ariana

No, that's perfect. I want your expertise and knowledge. So what kind of business training have you had? Do you have an MBA? Did you take some business courses?

Dr. Panero

No, I did not. I think I watched "Shark Tank" a lot and I watched a couple of these business shows and I really kind of enjoyed them. I think I've just always-- it became more like, hey, if I want to accomplish this, I have to get good at the business and kind of dive into it. Right? But it wasn't like I had the training. And like I said, I felt like I knew more about business until I actually got into it. I was like, wow, I really need to step it up. But I think it's about being consistent and about really trying to figure out, okay, from a business perspective, from a numbers perspective you know what are the things that are really impacting my business, right? So for instance, at the very beginning, you know we identified that we weren't answering phone calls fast enough. People were getting lost to follow-up. You know, It was taking a long time to get referrals in. So I really had to spend one-on-one time with that person that was bringing in the referrals and try to coach them up and find ways to make the process more efficient, right? Once we did that, it was, okay, where are we you know from a cost perspective, right? Are we losing-- are we paying too much for instance, waste management? Our phone services, right? Really looking at your P&L, breaking it down percentage-wise, and anything that's over 1%, you try to attack it and bring that down. Bring that down. Process credit card fees, right? If you're doing a lot of cash pay, how much money are you losing there? You'd be surprised. You could lose $20,000, $25,000 a year just on credit card fees, right? I think you have to constantly be looking at the P&L and don't feel like you just do it once a quarter and you're done. No, it's got to be an active process, right?

Dr. Ariana

And for those who maybe don't have their own business or when I opened my own business, I didn't exactly know what a P&L was. So just to clarify, P&L is the profit and loss. That's what most people who own a business know-- how they know their numbers. So for those of you who don't know what a P&L statement is, it's a profit and loss statement and just tracks your numbers. I didn't know either until I opened up this book, literally, "Business for Dummies". It was the yellow-covered one. That's where I learned all of the terminology and all these things. It's like, I don't know any of this. How do you go from zero knowledge, which we got zero knowledge in medical school, in residency, and fellowship. And so ultimately, how do we learn these things? Can you share any-- like really nice resources that you use kind of to get smarter at business or use them as a guide to help you be smarter at business?

Dr. Panero

Yeah. I think it may also be surrounding yourself with the right people. So for instance, with, you know, P&Ls and balance sheets, right? Yeah, you can sit there on a Saturday and try to reconciliate your accounts, right? But it may be worth just investing in an inexpensive bookkeeper, right, that can really, you know, take care of it for you and therefore it's there, it's organized, you can make changes to it and it's much more efficient and you can just evaluate the results. Finding a good business attorney, right? Finding a really good accountant. I think it's really setting up the team around you. And remember that if those services are not working out for you, don't be afraid to reach out and change them. You know, I've changed the accountants. I've changed attorneys, just like people sometimes change doctors, right? You got to find the ones that are willing to work with you. As far as resources, to be honest with you, I really haven't used books. I'm more of a watch TV guy. So I was just been on the business channel and trying to find ways. But also I say speak to your friends, right, that have businesses and hey, how are they doing it? Another you know, good acronym, I think, is ROI, right? Return on Investment. And understanding how to calculate, okay, if I'm going to spend you know $5,000 a month on Google ads, you know, how many patients do they have to see me? And I have to convert into a patient for that $5,000 to make sense, right? And I think anytime you're going to invest money, I don't know, you're going to get a new shock wave machine. Okay, it costs X amount. How many patients do I need to see before I pay the machine off? And where does that become profitable, right? And I think that really understanding, you know, again, profit and loss, return on investment, and what's another one? And also I think from a financial standpoint is when to take out money, right, when to take out a loan, understanding your interest rates and how are you going to pay off those amounts. I think if you can do those three things right while keeping really high-level customer service, you're going to do well.

Dr. Ariana

Awesome. So you say your practice is about 50% orthobiologics. Have you always had it be 50% orthobiologics or has it ramped up over the years?

Dr. Panero

Well, I would say it's 50% cash-based.

Dr. Ariana

Okay.

Dr. Panero

I would say you know, I've always been a fan of-- I didn't just want to be an orthobiologic clinic. I wanted to be able to provide all the services. And orthobiologics is what we're known for and kind of the staple of the practice. So it is that. I think a lot of people you know within the community, we are the orthobiologics clinic you come to, and therefore people are seeking us out and coming directly for that. And then the rest of the population is offering it as another option. It's just another big tool that we have in our box, right? But it does take some time. I would say that that didn't happen overnight and probably took a good you know, 3, 4, 5 years before it really became that. And I would say just in general terms for people who are listening, that's how long it likely takes. The first one or two years are kind of up and down, especially if you're solo and you don't have an immediate influx of patients from somewhere else like a private practice or an academic center. And then by year three, it really starts to kind of plateau and get where you're consistent. And then by year four or five, that's when you see a lot more growth, at least I did. And then it's just about really trying to, okay, how do I keep this rolling? How do I not get overwhelmed? And making sure that you build a structure or a scaffold in your practice, right, that's strong enough to sustain that. Because if you don't do that early, as you start to get busier, your customer service and your ability to see people, you know, will essentially crumble you. So that's why I think it's really important at the beginning to have-- you know, spend the time with your staff, building processes, building ways that things are going to be efficient, that if I increase my volume, my staff and myself can still sustain that. So I think that's a really important piece.

Dr. Ariana

Great. Yeah, thanks. What do you see as the main benefits of integrating orthobiologics as an option in your practice?

Dr. Panero

You know, I think it starts with the science and the benefits to the patient, right? It's another pathway. For a long time, we've been using physical therapy, which can be great, you know, steroid injections, medications, braces. And if they failed that, it was kind of a surgical intervention. Right? And I feel like with orthobiologics, we just now have another pathway. And in a lot of scenarios, it can actually heal things you know, like small tendon injuries, tendinopathy, muscle injuries, and in other things like osteoarthritis, it's just a better almost like chronic disease management, right, where, hey, okay, you may not be curing the osteoarthritis, but it's much better than, for instance, a steroid injection. It's been proven to be better than hyaluronic acid injections, and it's going to give you longer, better pain relief. And there's nothing wrong with that. I feel like you know, the stigma behind orthopedic is when it first started, it was all about this, hey, we're going to put this magic PRP or stem cell in there, and it's just going to fix everything and regrow your brand new knee. And now that we've done it for a while, we're starting to see, okay, where are the things that it can actually heal things, right, versus where, hey, this is osteoarthritis is a chronic disease, and this is just another better management option. So I felt like to me, it was just a natural transition to provide a patient with a better option. And that's how we were able to integrate it with the practice.

Dr. Ariana

Awesome. So can you just share kind of from a day-to-day experience as a business owner, how you spend your days, like Monday through Friday? I know at some point, if you're running a business, you have to have some administrative days as well. Can you share how you spend your days?

Dr. Panero

Sure. Well, now, with the help that I have and been able to build BIOS, I have been able to carve out about 2-3 half days a week where I'm doing primarily administrative stuff. And that can vary from you know having meetings with my clinical director, going out. I still go out personally. I'm a big believer in still going to physician offices, going and thinking, referring providers, and making sure that the process for them sending us patients is still fluid. I'm a big proponent of that and still showing my face. And then lastly is the running the business side. I think you have to stay on top of the numbers, seeing what the business is doing, making sure that the numbers are still doing well, and identifying areas of improvement. And then for practice, what we've done is we kind of segmented where, for instance, Mondays are our fluoro days, and we're just doing all the fluoro cases that day. Wednesdays and Thursdays are our primary orthobiologic days, and then the rest, we do a mix of new patients and follow-ups.

Dr. Ariana

Great. Awesome. What did you see was your challenge, either personally or professionally? How did you do this business owner part as well as working as a physician in your business, as well as having your family and loved ones? Have you come up with any hacks to make that easier or is that something we all struggle with? Maybe just if you can share that, that'd be great.

Dr. Panero

Sure. I think it is very challenging and it's probably of the-- as you know, one of the hardest things to balance it all out. You know for me, I just always try to put my family first and really devote dedicated attention to them. And if that means you know waking up earlier or staying up later, but still making sure that I still am able to be very present with the family, right, because I think that that's at the end of the day what's going to lead to the ultimate happiness. Now, from a business perspective, I think unfortunately at the beginning, you just have to be willing to grind, right, and willing to put in the time and the hours and just kind of staying on task. And I think one of the best things you can do is just be ultra-organized. Making sure you're constantly checking and rechecking, whether it's your task list, whether it's your schedule in your calendar, and making sure that you can stay on task. And especially when you assign tasks to your staff, don't just tell them something and then pretend it's going to get done, you know, and then six weeks later, it's already finished, right? Same thing with your consultants, like your attorney. Or for instance, in my case, if you're building out a project, right, you really have to stay on top of everybody. Building out BIOS, you know was a big challenge. And I learned that I had to stay on top of the attorney doing the work, the landlord following up on their promises. When you go to get your general contractor, making sure that you're checking in and consistently following up on the project. Because, you know, what happens is you're like, well, I don't know anything about general contracting. I'm hiring him. You just expect him that he's just going to do his job, right? Unfortunately, it doesn't always work that way. And you have to advocate for yourself. And anytime you hire any of your consultants, even your accountant, you want to be consistently checking in and following up on their work, not, you know, assigning a task and then hoping it's done three months later. Unfortunately, you have to stay engaged through the whole process.

Dr. Ariana

Got you. So what information do you wish you had at the outset of your private practice journey that would have been super helpful going in?

Dr. Panero

Yeah. Well, I think one, you know, how long it's going to take. Right? I do feel I've accomplished a lot and I'm very proud of it, but, you know, it's a slow process, right? The years go by and you're in it and you're in it, right? I would say, you know, grow out of necessity. If you're not ready to take the next big step and you're in a place where you have low overhead and your costs are low and patients are coming in, don't be afraid there to stay for a little while and build up the reputation of the nest egg and then take the next step. Don't feel like you have to open up, you know the big thing right away. You can definitely stay in kind of a smaller model for a little while until it grows. The other thing is-- you know, to the point I was making is when you start to go into business, right, it's a cruel world. And working with landlords and real estate and different contracts, you have to be prepared that as a small private guy, you're not going to have the leverage that you may want. And even though you're going in it in good faith, right, to do things the right way and maintain your promises, the other people that you're working with or against may not be. So be prepared for that. Be prepared for the fact that, you know, for instance, a landlord may have a lot more-- you know you've both signed the same agreement, right? But the landlord can have a much bigger leverage to make you comply on your terms of the agreement while they sign the same agreement but in order for you to make them comply to their agreement can be a lot more challenging, right? So just beware about that and make sure that you really have a good attorney and someone who's really going to be looking at things in your favor.

Dr. Ariana

Awesome. What advice would you offer a physician who is contemplating adding orthobiologics to their existing practice?

Dr. Panero

Well, number one, you know, do it for the right reasons because you believe in the science and you genuinely feel that these are the right things for your patient. Two, be meticulous about learning the science behind it. I think sometimes we forget, or I didn't realize how much basic science went into understanding these procedures. And if you do that, you're going to be able to really understand why you're doing these procedures, which leads you to then pick the right patient candidate, right? And make sure you're not just injecting everybody with everything. Making sure that you're trying to really be meticulous about who you inject, how you inject it, and why you're doing it. And then lastly, you know, got a plug here, go to the good courses, right? IOF, for instance, you know try to shadow some of the physicians that are doing it. Try to really be as evidence-based as possible behind it. And there are a lot of really good resources and a lot of good people that are willing to share their knowledge, so why not tap into that?

Dr. Ariana

Awesome. Awesome. So if people want to know more or want to get in contact with you, how can people reach you?

Dr. Panero

The best is through our website, "TheBIOSInstitute.com". Also, we have an Instagram handle that we try to update as frequently as we can. As you know, running a business, that's another side we could probably have a whole podcast on, right, is social media in the era of medicine. But yeah, I think those would be the two best ways to contact us.

Dr. Ariana

Awesome. Well, thank you so much for joining us. This has been Alberto Panero, and this has been "The Business of Orthobiologics" podcast. Thanks so much and we'll see you next time.

Dr. Panero

All righty, have a good one.

Outro 

This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more, please join us on the website, "PRP-Now.com" and click on the FREE Masterclass. Also, don't forget to "SUBSCRIBE" to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.