Interview with Dr. Walter Sussman

Meet our special guest, Walter Sussman, a renowned Physiatrist with extensive fellowship training in Sports Medicine. Hailing from Boston, Walter brings a wealth of knowledge and passion to the show. Discover the extraordinary story of his career, from his academic days to becoming a trailblazing practitioner in the heart of Massachusetts.
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Don't miss this captivating conversation that offers valuable insights into the world of orthobiologics and private practice. Whether you're a healthcare professional or just intrigued by the healthcare industry, this episode is a must-listen!

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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 value of Orthobiologics, patient selection, how to talk to your patients about money, office set up, 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

Welcome to "The Business of Orthobiologics" podcast, where we discuss practical applications of orthobiologics in orthopedic practices. From hybrid practices to full cash practices, our experts will share real-world experiences and success stories. So listen up, stay inspired, and unlock new possibilities. Today we have Walter Sussman, who is joining us from Boston. And thank you so much, Walter, for coming on the show today. I really appreciate it. So if you would like to just share a little bit about you, what your specialty is, and how long you've been in Boston, that would be great. So welcome. Thanks so much.

Dr. Walter

Thank you. So I'm a physiatrist by training. I have fellowship training in sports medicine, and I moved back to Boston after fellowship from Massachusetts, my family's from New England, and so I was coming home. Been here ever since.

Dr. Ariana

Awesome. Did you do a fellowship? Where did you do your fellowship?

Dr. Walter

So I did my fellowship in Atlanta with Ken Mautner at Emory, and they were kind of pioneers with a lot of the biologic stuff. So I got my exposure there and transitioned that into practice.

Dr. Ariana

Awesome. So, now, did you start at where you are now, or where did you start after fellowship? Kind of take me through your journey of where you started out. Have you always done cash practice? Have you always done orthobiologics?

Dr. Walter

Yeah, so I left the Emory model, and it was a great hybrid model with physiatry and sports medicine, orthopedics, you know in this really collaborative environment, and was really searching for that when I left fellowship and found that in a small private practice in Massachusetts. And so I joined them a little over eight years ago and worked with them. They ended up getting bought out by a larger orthopedic group, and I branched off and opened up my own practice.

Dr. Ariana

Okay, so how long ago did you say, gosh, I don't know what this small orthopedic practice got taken over by a larger orthopedic practice, then you left and branched out on your own, is that correct?

Dr. Walter

Yeah.

Dr. Ariana

And how long did you make that decision?

Dr. Walter

About three years ago.

Dr. Ariana

Okay.

Dr. Walter

Almost four years now. I really like having the flexibility to spend time with my patients, you know, having a little more control over my schedule, being able to cater to patients, having a little more control over my staff, and holding on to staff members who do a really good job. And I worried that the larger corporate kind of environment would have impeded on that. So that was a big part of the decision. It was also at the time with Covid and seeing how the groups were dealing with my staff members, my team members who had been working for four years and just having a hope that I could do that in a better way.

Dr. Ariana

Yeah. So in Boston Covid was pretty rough for-- there was a pretty big lockdown. Yeah?

Dr. Walter

Yeah. Not only at the practice level but the hospital being able to get procedures done. So we had to make a lot of adjustments and move a lot to telemed. We lost a large percentage of our employees. People had been with us for a long time. I think we're starting to see the light but you know, it took a while to recover.

Dr. Ariana

Yeah. No, I hear you. You know I opened up my practice just before Covid so I'd been open for like nine months and then whammo and we all kind of had to figure out what the heck to do and I think everybody we didn't know and so I hear you. There are different ways that we all deal with it. Some people hunkered down and said, okay, we're just going to wait this out. And some people said, okay I'm going to pivot. Some people said, heck we're just going to be closed two weeks. I'm just going to stay open, it's going to be fine. So yeah, I think everybody had different responses. Now, are you in your own building? Do you own the building, rent the building, lease the building?

Dr. Walter

So we lease our space. It's a great space. It's an area where there are a lot of medical buildings and professional buildings. We're a legal building so it's actually nicer because there's less foot traffic but it's a great space. In the Boston market, it's hard to own property here, especially for me who is starting out.

Dr. Ariana

Yeah. So what square footage is your office space right now?

Dr. Walter

So we started off with 15,000 sqft.

Dr. Ariana

Okay. Cool.

Dr. Walter

We really thought that it was going to be kind of a micro practice and we got busy pretty quickly, so we actually leased out the space adjacent to us. We're just under 5000.

Dr. Ariana

5000 sqft. Okay. Now are you the sole owner of the practice? Do you have partners? How does that model work?

Dr. Walter

Yeah, so I'm the sole owner. We're a C Corp. And with the idea that at some point be able to grow, we've hired two docs in the past year who are employed physicians. So we're starting to grow.

Dr. Ariana

Okay, so you're a C Corp. And then you as the doctor are a W-2 employee, and then you have two more doctors that are W-2 employees for your C Corp. Is that correct?

Dr. Walter

Yes.

Dr. Ariana

Okay. And then is there any kind of buy-in opportunity or they wanted to be employed? How does that look for you?

Dr. Walter

Yeah, so they just started, you know, so figuring out that and what that structure is going to look like is stuff we started to play with those ideas. Fundamentally, I don't think doctors make really good employees. I think that bringing them on partners at some point is if they're a good fit for the practice, they can produce and help with overhead. But I don't know exactly what that structure is going to look like. And I've been fairly straightforward with our new hires about this stuff.

Dr. Ariana

Sure, yeah. I don't think there is a model that has been proven to work every time. And, I mean, from my perspective, I'm a horrible employee. I don't really do well with people telling me what to do. So I hear you. You know, other doctors may not want the other parts of the business that go with it. So can you kind of bring me up to speed on, like, you had a build-out, and then-- is that true? You had a build-out and, like, rent off for your office? How long did that take?

Dr. Walter

The initial one was pretty quick. We had a tight window, and so within six weeks, they were able to get permitted and build out the space. We had our landlord do it, which helped a lot in cost, but just the speed of doing that project. Interestingly, even though that was at the heart of Covid we had more supply chain issues with our second build-out, our expansion, which took a lot longer, five to six months because of a lag time with a lot of supplies.

Dr. Ariana

Okay, so in the first startup, how did you know how to create this business? How did you figure out, like, oh, well, I want to start a business, of course, I know what to do. How did you get that knowledge?

Dr. Walter

You need a lot of people to help you out. We started with a healthcare accountant to kind of build a P&L.

Dr. Ariana

And just share with everybody, because I didn't know when I started my own business in 2010, I didn't know what a P&L was. Just for everyone who doesn't know, that's a profit and loss sheet. Didn't know that in 2010 when I started my business. So I'm just helping to educate.

Dr. Walter

Yeah, and I didn't either. I got plugged in with somebody who could hold my hand with that. Half the challenge is trying to project what you can make and what your profits are going to be. And when you work as an employee doc, you're not necessarily privy to those numbers. So you have to figure out how many patients you're seeing a month, what procedure volume is and those numbers and that can be a challenge. So as I started playing with this idea, keeping track and trying to get our hands on hood, and when you're not seeing receipts, you're making basis, numbers based on other data that's out there. So they're kind of rough estimates and then trying to dial in on costs. That's another anything from your EMR. You may not know that in the beginning. So there's a range in phone and internet costs and potential employee costs. And so having somebody who can kind of walk you through that and then he helped plug us in with business consultant, real estate person to help us find space, a banker to help with financing. So, you know you really need a team.

Dr. Ariana

Do you think if you had to do it again, would you do it the same way, or are there things that you would do differently knowing what you know now?

Dr. Walter

Yeah, I think starting early with the numbers piece, that really is what took the longest. Trying to make those projections and then working with the bank to have somebody take a risk on us.

Dr. Ariana

Did you get accepted by the first bank that you applied to?

Dr. Walter

No. Apparently, dental practices are a big thing, and funding them, and so that was their model. And this was kind of novel and not something they wanted to take risks with. So the second group we worked with, we got approved, so that was the biggest time crunch. And so I think starting really early with that, giving yourself a year, kind of make sure that that goes smoothly. It's stressful when you don't know if your financing is coming in and your lease is about to start and trying to figure that out.

Dr. Ariana

Right. So you said you based your projections on numbers that were out there. You know, when I started to try to find what was out there, what the prices were, all I could find was Medicare numbers. And so I really struggled because I didn't know, I didn't know how to set my prices. I didn't know because you're not privy to what the contracts say. If you're working as an employed doc or you're working in an insurance-based practice, you have no idea. So what kind of numbers did you use?

Dr. Walter

So we use CMS kind of as our basement assuming that some of the private payers would be better. So in general we're pretty conservative or I'm pretty conservative in terms of those numbers. I'd rather project lower and hope that we're higher. I did get presented with a quarterly sheet with what I actually filled out and what I collected so even though I kind of broke that down, I could see that the CMS number should be on average what I was pulling in. Having hit a steady state in my old practice and know that that's probably our range.

Dr. Ariana

Gotcha. Gotcha. So you're kind of using your old data and trying to project and do a little math and be like, all right, well, I think this is what was billed out. This is what I got back. So it's like a third of the price.

Dr. Walter

Yeah.

Dr. Ariana

And then, okay, so CMS, that's how much you get. Okay. Cool, because I struggle with this a lot. Did you have any business training before you were like, I know what I'm going to do, I'm going to open my own practice.

Dr. Walter

I didn't. So my practice manager had worked with me at the old practice and had just started business school, so when I went off on my own, I relied on her first year of business school training.

Dr. Ariana

Wait, so wait, go back. Have you started business school?

Dr. Walter

No, my practice manager, my current practice manager, worked with me at my old practice.

Dr. Ariana

Okay.

Dr. Walter

She started business school, and so I don't know if I would have done it without kind of the people around me. I think having a support network is important in knowing what resources you have to kind of rely on. And she knew a lot more of the front-end stuff, too, a lot more of the insurance piece than I do and still handles a lot of that of the practice. And then as practice, essentially paid for the rest of her business school to have her come on board. And so that partnership really was a big part of making me feel comfortable taking.

Dr. Ariana

Yeah. I was like, wow, you went through business school. That's amazing. Gosh, you were awesome as is. Anyway, I think that I want to know what's the best decision that you've made in business thus far? One that's maybe surprised you, where you're like, man, looking back, that was fantastic.

Dr. Walter

I think we got lucky with a lot of stuff. I think that our initial projection was that we were going to be really small. We were going to kind of creep along. I think we got lucky with our space because we had an adjacent space that we kind of built into. And so, you know, one of the challenges we faced early on is we got busy pretty quick, and we had to make a decision. Are we going to have a really long wait list and see a small number of patients? Are we going to start ramping up? How many patients are going to be coming through the clinic? How do we make that transition? And that required us to have more space, you know and to hire additional providers, too, to support the additional overhead of front-end staff. It's required to get authorizations and deal with the insurance company.

Dr. Ariana

Yeah. So you are a hybrid. You take insurance and you take cash. Yeah?

Dr. Walter

Yeah.

Dr. Ariana

Okay. And you've always been hybrid, and that was your fellowship model as well. Now, in your fellowship, it was academic. It was at Emory, right? Or was it a private practice type of model?

Dr. Walter

It's a big academic center, but they really run the orthopedic department, similar to how a private practice would run.

Dr. Ariana

Okay. So you had some knowledge of, like, oh, okay. Now, did you still have ties to your fellowship where you reached out and you're like, holy cow, I don't know how to do this? Is that something that ran through your head or you were feeling pretty supported with your team around you?

Dr. Walter

Yeah, I thought I had a good team. A lot of consultants who were really helpful early on make some of these decisions, and so it's still an academic center. They still have the broader support of a large system behind them. That's different in private practice.

Dr. Ariana

Yes, it is. I agree. So from a volume perspective or percentage perspective, how much is insurance-based? How much is cash-based?

Dr. Walter

So, you know, I still like to do a lot of the primary care sports medicine, you know, the non-operative, non-procedural kind of stuff. And so we still see concussions. We still do a lot of joint injections, tendon injections, and hydrodissections. Tenex is a big workhorse in our clinic. And Sonex. And so, you know, those are all things that are covered by insurance and play that game. The biologics is about 20% of our receipts.

Dr. Ariana

Okay.

Dr. Walter

About 10% of our patient volume.

Dr. Ariana

Okay. So 2:1 ratio, basically.

Dr. Walter

Yeah.

Dr. Ariana

Okay. All right. Yeah. I mean, you are the Tenex king, right?

Dr. Walter

Yeah. So it's harder-- I mean, those aren't cheap procedures. You know, we do some of them in-house. We have a big procedure room where we can do them here, but it's not covered by insurance. So navigating that system.

Dr. Ariana

So in your practice, if you do Tenex in-house, it's not covered by insurance.

Dr. Walter

Correct.

Dr. Ariana

It's a cash procedure. But if you do it at a surgery center or ASC procedure suite, then it's covered by insurance. And then you bill out your provider fee to the insurance, is that correct?

Dr. Walter

Correct.

Dr. Ariana

What would be the instance where someone would choose to have that in-house versus at a surgery center? What's your common experience for that?

Dr. Walter

So we have a couple of international patients, and just navigating that with the hospital system is challenging [inaudible].

Dr. Ariana

Yeah.

Dr. Walter

We're seeing more patients with very high deductibles, $15,000 deductibles. Doing anything in the surgery center is going to eat up a big chunk of that. So it's cheaper for them to do it in the office. It's at a lower expense.

Dr. Ariana

Sure, that's great. So are you working five days a week right now, or do you take time off?

Dr. Walter

It's five days a week. There's some administrative time built in, but that's also our overflow time for patients that have to get in.

Dr. Ariana

Got you. So can you kind of walk me through your weekly schedule, like what you do day to day, and then when do you fit time in for your family and your kids and hockey, and stuff?

Dr. Walter

Yeah. So it's eight to four. Tuesdays are a little lighter of the day. My wife's a vet, so that's her surgery day. So I take the kids to school, I pick them up, and then Thursdays is two cases in the ASC, and we do as many cases as we can book and then an afternoon, that's our admin time or overflow time. We're still doing a fair amount of telemeds, so we try to get the staff out a little early and do the telemeds at the end of the day. So it's not necessarily always to four. Sometimes we end early and do the telemeds, but five days a week, and it's challenging early on. We've only been open for two and a half years, so there's a lot of stuff to set up. We're still working on it, you know. It's easier now, but I have a little more time for family. But it's tough those first couple of years, to find that balance.

Dr. Ariana

Sure. And then you've been doing quite a bit of publishing and research and all of that. Where do you fit that part in?

Dr. Walter

Yeah, we're a training site for the Tufts PM&R residents. They'll spend time with us, and anything from case reports to systematic reviews and anything in between, I like to do it because I think it makes me a better doctor to review the literature and know everything that's out there that I can. And so I enjoy doing that, but there's not a lot of time during the day to fit that in.

Dr. Ariana

Yeah, no, I hear you on that one. So what do you think has been the benefit-- what do you think is the biggest benefit of integrating Orthobiologics into your standard PM&R sports medicine practice? Where do you see the huge benefits from biologics?

Dr. Walter

You know, it's a tool like any of the stuff that we use, you know. And so trying to figure out exactly what's going on with the patient and what their options are is the primary goal. Using diagnostic ultrasound to really dial in on the source of their pain, differential injections to really figure out where the pain is coming from, and then figuring out what's the best option for them. And it may be continued therapy. It may be a cortisone injection or a viscosupplementation injection, in certain cases. Hydrodissection, and then shockwave, PRP, the BMAC, NFAT, all these are options. But figuring out where they are in the process, how bad the pathology is, and then figuring out what's the best and fastest way we can get them better at the least expense to them.

Dr. Ariana

Sure. In your perspective, you've been in the game long enough to understand when people are presented with the option to pay cash, what do you think makes their decision? So you're giving them all these options, and they're like, you know, nope, I want the one where I pay cash. What do you think is the game-changer for them? I've been trying to decide this myself, so there's no right answer, but I've just been kind of toying with what changes their mind, what makes a decision? Is it like to return to sport? Is it how long it lasts? What do you think it is?

Dr. Walter

I think it differs a lot. It's very personal for some patients, and we definitely have patients where cost is a challenge somewhere it's not. I think a lot of what they've done historically matters. I think what friends and families have done, if they've had exposure to this, I think that weighs very heavily. They're considering it.

Dr. Ariana

The word of friends is helpful?

Dr. Walter

It's helpful, you know. I don't know. I think you have an honest conversation about all the options and what the data is on this, and then it's raised shared decision-making in terms of where we start. And just because we start with one treatment doesn't mean that we burn bridges with others. So I think if all you present is orthobiologics in most cases or it's a heavy cell, patients pick up on that, and I think it's a turn-off. And I think that that's the biggest difference, is being able to offer them options.

Dr. Ariana

Yeah. A continuum of care. This is just one more tool in the tool belt. Yeah, that's kind of how I've been realizing that it is well received. And don't go in with guns ablazing just orthobiologics only. Okay. So what do you think has been the biggest challenge for you professionally in opening this practice and doing things? What do you think has been the hardest part to kind of either master or the hardest pill to swallow? Walk me through that.

Dr. Walter

Yeah. I think there are a lot of regulatory, laws, rules, and ethical guidelines that we're not necessarily presented with. We're taught stark laws and some very basic stuff in medical school, but figuring out which form a patient needs to sign. If you're going to do biologic and they have insurance, what covers you in that situation, not charging their insurance, and how to navigate some of these regulatory issues? Do you bring in some of these ancillary services, and is that okay? In some states, you can potentially sell supplements. Some states have guidance in terms of that. So I feel like there's a lot of these little minefields. We have an outside compliance. A company that comes in and they review all of our documents and they tell us what we're missing. And that was something that we did early on just to try to cover our blind side. You don't learn that in medical school.

Dr. Ariana

Right.

Dr. Walter

So those are things that keep me up at night.

Dr. Ariana

Right, I hear you. What do you think has been the most difficult part from a personal standpoint or family standpoint? What do you think is really something that you've struggled with? And then maybe some insight on how to avoid this?

Dr. Walter

Yeah, this takes up a lot of time. It's not something that just comes together on its own. Right? You need a lot of people around you. You need a lot of support, and your mind is here a lot. When you're first starting out. So even when you're home and you're trying to be present, a time when you're home, making sure that you're present when you're home, I think is a challenge when you know that you have to review these documents after the kids go to bed and stuff. I think that the beginning part, making sure that all the t's are crossed and I's dotted and stuff occupies a lot of time, both hearing and away, and then balancing that with seeing 20 to 30 patients a day. It's tough to figure out how to divide time.

Dr. Ariana

Yeah. What information do you wish you had at the outset of your journey that maybe would have made it easier?

Dr. Walter

It's a good question. Hindsight you know being 2020.

Dr. Ariana

Of course.

Dr. Walter

I think the journey is the reward of this. It's hard to anticipate everything. I think, again, we got really lucky with having a good team around us. And so even our mistakes we learned from them. I think that that's the most important thing is to know how to react and not be stuck or paralyzed by changing gears or dogmatic with anything.

Dr. Ariana

So what advice do you think you would offer a physician who's either contemplating, stepping out on their own, or they're in private practice and they're really considering adding a cash-based component to their practice? What would you offer as an advice for them?

Dr. Walter

I think the cash-based procedures make sense. It makes us better doctors to be able to offer more options to patients, especially stuff that works and has data behind it. And as far as this first part of the question stepping out, I think that doing it for the right reasons may or may not make more money. It may or may not give you more autonomy. And so figuring out why you're doing it will kind of drive you in those tougher times.

Dr. Ariana

Sure. Now, here's a question. Would you go back to the way you were working before in the other practice? Oops, I think we've frozen him. So, Walter, the best question is, would you go back to the way you were practicing prior to opening your own practice?

Dr. Walter

No. You know, I love coming to the office every day. You know I'm really proud of what we've done. I'm proud of the team that we've cultivated, and I'm proud of the experience we can provide to patients, which I think was a challenge when I had no control over my schedule and little things. And just to kind of cultivate that experience from start to finish. And so I can't imagine going back and practicing as an employee doctor.

Dr. Ariana

Right? Yeah. I mean, when I've been asked that question myself, and I said, not even for a million dollars? No, I don't think I would, you know? I'm not even sure if it's 2 million. And, you know, everyone has their price. But man, I tell you what, I hear you. It is so nice to be able to cultivate that practice, cultivate that experience for your patient so that from start to finish, it's impeccable and they really feel cared for. And they are cared for in a completely different light than your usual practice. So awesome. Well, where can they find you? If they want to know more about Walter Sussman, where can they find you?

Dr. Walter

So we're outside Boston in Wellesley, so it's about 10 miles outside the city to the west. Our website is "BostonSportsandBiologics.com" or "BSBortho.com".

Dr. Ariana

Awesome. Well, thanks so much for joining us. This has been "The Business of Orthobiologics" podcast, and I am so thankful for you sharing your experience with us. And until next time, there is always more to learn, and thanks so much. We'll talk to you soon and tune in next time. Thanks so much. This has been a wonderful time and this has been "The Business of Orthobiologics" podcast. Thank you so much for listening. Hopefully, this has been helpful. This has been Walter Sussman from Boston Sports and Biologics. And obviously, I'm Ariana De Mers, your host of "The Business of Orthobiologics". So until next time. We'll talk to you soon. Thanks so much.

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.