The OG of Orthobiologics: Interview with Dr. Don Buford

Dr. Buford, known as the "OG of Orthobiologics," shares his journey into orthobiologics starting in 2008 and emphasizes the importance of perseverance, even in the face of initial negative results. Now, it constitutes approximately 70% of his gross revenue, indicating a significant shift in the focus of his practice!
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Transcript

Intro

Hey, I'm Dr. Ariana DeMers. 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 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

Welcome to "The Business of Orthobiologics" podcast. We discuss practical applications of orthobiologics in orthopedic practices. From hybrid practices to full-cash practices, our experts share real-world experiences and success stories. Welcome to Don Buford, who founded Texas Orthobiologics, clinics where patients can get an unbiased orthopedic diagnosis and a complete discussion of their non-surgical and surgical treatment options including orthobiologics and orthopedic surgery. Welcome, Don. Thank you so much. As everyone may or may not know, I call Don Buford the OG of orthobiologics. I'm not sure if he hates it or he loves it. But, yes, welcome. Thank you so much for spending your time with us. I want to know a couple of things, and our listeners are wondering all of the things orthobiologics. Can you share with them your specialty and how long you've been using orthobiologics in your practice? So take me through your journey a little bit.

Dr. Don

Sure thing. First of all, thank you for the invitation to be on the podcast. I've been a steady listener from the beginning.

Dr. Ariana

Thank you.

Dr. Don

And just really impressed by what you've put together here. So congrats on that. So my journey-- I guess I started in practice coming out of a sports medicine fellowship back in '99.

Dr. Ariana

Like two years ago, right?

Dr. Don

Yeah, just a hop, skip, and a jump ago. It wasn't until about nine or ten years into practice that I really was exposed to platelet-rich plasma, which was the first real orthobiologic that I was exposed to. It wasn't even in this country. It was internationally at a meeting that I was at. I just remember being interested in what was being presented, hadn't seen much on it in the United States. Obviously, had none of it in residency or fellowship, none of that info, and just came back and just got real curious about it. And it would be a lot easier now because the internet's kind of you know, gone off and become just a tremendous resource. But back then, it took a little bit more work, but still, I was able to contact some like-minded people and just got involved from the clinical aspect of it about 2008. I think that was the first study that we did trying to see if we could come up with a solution for partial thickness rotator cuff tears. And that was a study that we ultimately presented at [inaudible]  all those years ago. It was interesting in that result was not positive. It didn't really show that it helped. And of course, this is a different version of PRP that far back in the past. But isn't it interesting how sometimes the negative results, if you're curious, keep you looking? I didn't give up. It just made me think, well, you know, everyone can't be crazy. I must be doing something wrong, or there must be a better way to do it. And so from that early, I shouldn't say negative, because I think all studies, regardless of conclusion, are good studies that may contribute. But from that conclusion that PRP wasn't helpful for that application, that really cemented my interest in orthobiologics because I knew that it wasn't just to draw something in and it was a syringe and inject it. It had to be more complicated than that. So that's where I started, and it's just grown since then, as you know. And clearly, it's become the direction that orthopedics is heading in. We've all been practicing in a time where the materials, the anchors, and the implants, and even the techniques for the most part are pretty good, pretty darn good, and pretty hard to improve upon success rates that are in the 90%. And so biologics is really the way to go. Whether we're helping with the surgical outcome or ideally helping people a little bit farther upstream before they need surgery. So I think that's where our field is going. I think that's where it'll be a couple of decades from now.

Dr. Ariana

Awesome. Yeah, that's so fascinating. I think partial thickness rotator cuff tears for me is really still quite fascinating because I recall talking to my patients and being like, oh, hey, it's not a full tear, so you don't need surgery. So come back when it's worse. And that was it. I was like, and if you're really miserable, I guess we can do a takedown and repair. But I didn't have another option. I didn't have another solution. And I was like, I can't believe looking back that that was it. That was all I offered. I was like, oh, my God. Wow. I was really missing the boat. And it's interesting that you brought up that we have really good anchors and implants and widgets and ways to secure. But I have come across this thought that I think in making those parts better, I do think that we've somewhat neglected to think about the biology. I think we have forgotten that this is a biologic entity that we're operating on and that there is a biologic response and a biologic reason that these things fail. One of the thought processes that I've thought about is the root cause. Why did this happen in the first place? Is this a biologic failure or is this a structural failure or is it both? Because if it's just a biologic failure, then definitely orthobiologics is the solution. If it's just a structural failure, like a fracture or something, then absolutely structural repair is the solution. And then if it's both, like a rotator cuff repair, man, I think that there's the answer somewhere that it's both, you know. That's fascinating that you happen to bond that. I think you're such a forward thinker in the field, like the fact that you were like, maybe I should think about this. And maybe across the pond, there are some better opportunities to know about these things than in the States. And so that is a tribute to you and your ability to kind of take things as they are and bring them back home, if you will, to see what we can't figure out. But can you share with me a little bit-- how your office is set up? Because this is the business of orthobiologics. So can you share with me-- I know that you've been doing this for a bit. And just share with everybody. Are you in private practice or employed? What's your setup? Do you have partners? Are you solo? Kind of walking through that a little bit.

Dr. Don

I'm happy to. I've been in private practice for my entire career. I've never been an employed surgeon to date. And when I first came back to Dallas and joined the group that I'm still currently in, one of the things that was attractive to me was that they had a model where each doctor was basically their own island. All the islands are connected, but each doctor was his own island in terms of revenue and both income and expense. And so what that structurally means for us is we each have our own tax ID. So there is not one group name that bills for all of the doctors. Each doctor has his own tax ID and is free to be on whatever insurance he wants or not be on whatever insurance he wants. Where we intersect in our group is all of the clinicians co-own the management company, and it's the management company who's the signatory on the lease, who signs our employees' paychecks, and basically handles things like common supplies. Back when we had a radiology department that was under the management company's domain. And so structurally, every month, I, as Don Buford M.D.P.A., would get a bill from the management company stating that, okay, last month, your expenses-- your share of the expenses was X thousands of dollars, and I would cut them a check. They would not bill me for my own salary. That would come out of my own company. So I was essentially the only employee in my company which gave me some added flexibility in terms of retirement planning and tax planning. But the management company was co-owned by all of us. And just like owners of any other company. That company could then-- we didn't take salaries out of it, but we certainly took ownership income as owners out of that. So K-1 type income out of the management company.

Dr. Ariana

That's a pretty advanced strategy. Have you had business training? Did you get your MBA or did that just come like School of Hard Knocks?

Dr. Don

Yeah. No, I mean, truth be told. So I was an economics major in college and didn't get an MBA, at least not yet.

Dr. Ariana

Working on it. Good.

Dr. Don

Yeah, the School of Hard Knocks, like you said. But this structure was already established when I came into the group. And so the group that I joined, the Sports Medicine Clinic of North Texas, is one of the-- if not the original sports medicine group in Texas. And the original founder of this group was for many, many decades, the team doctor for the Cowboys and actually all of the sports teams in Dallas. And so before sports medicine was even a thing. So J. Pat Evans was an amazing guy. I got a chance to meet him because even though he was retired, he was still coming around when I first came into the group. But that was his kind of brainchild, the structure.

Dr. Ariana

Right.

Dr. Don

And, you know, it's pluses and minuses. If somebody is entrepreneurial and motivated, and if I had known back then what I was going to be doing now, I would have designed it exactly the same. It's perfect for what I do. But if somebody is in a situation where they don't want to manage employees, they don't want to deal with a lot of business, then those are our colleagues that are going into the more salaried positions because there is a little bit more work. But I think the reward is far away the extra bit of work, at least for me.

Dr. Ariana

Absolutely. Now, are you taking insurance? Do you contract with commercial insurers or where are you at in that perspective?

Dr. Don

Yeah, so all the way through, for the last 24 years, I've been part of a group called Southwest Physicians Associates, and it's basically a negotiating group. You know, we're not allowed to unionize, and we're not allowed to co-negotiate with insurance companies. But what we've always been able to do is to be part of an organization that can at least work on the details and the contracts that the insurance companies give us, and make sure that each clause is as doctor-friendly as they can make it. And the other real benefit for them is they take all of the fee schedules from all the insurance companies and they put it on the Internet. So I can go in on a web page, pop in a CPT code, and see what I'm supposed to be paid from that insurance company. And so they manage my insurance contracting. I still take insurance. I still operate, and I feel obligated to take insurance for that. I've had a partner actually who's done that experiment multiple times where he went off a particular insurance company that may have frustrated him with their preauthorization requirements and other non-payment. And even ten years ago, which is I think the first time he did it, we were already commodities in the business as surgeons, meaning that when he went off of, I don't say the name of the company, but when he went off of one company that had 30% of the business, he lost almost exactly 30% of his business. So people weren't coming to see him out of network just because he was who he was, even though they loved him. At some point, the money that you're paying every month for premiums and that $5,000 deductible, most people can't just ignore that for surgical problems. So that's why I stay on insurance. Obviously, with orthobiologics, I have less and less insurance as a percentage of my practice.

Dr. Ariana

What percentage of your practice is orthobiologics versus surgical and non-surgical insurance-based care?

Dr. Don

Yeah, it's a great question. And there are a lot of ways to answer that because the easiest way is if we answer in terms of what percentage of gross revenue?

Dr. Ariana

Yeah, sure.

Dr. Don

Yeah, then it's probably 70% of my gross revenue now.

Dr. Ariana

Okay.

Dr. Don

Even if the reimbursement from orthobiologic stayed flat because insurance is doing this, that percentage continues to go up. So it's probably a solid 70% of my revenue. In terms of the patients who come in to see me, I've noticed a significant increase in people who come to see me because I do orthobiologics. It's at least 50-50, if not even higher, probably tracking pretty closely with the gross revenue number. And because our marketing is very clear that we are positioned as a concierge medical practice, we aim to be a one-stop shop. We don't just have a hammer. We don't just have a syringe and a needle for an injection. We don't just have a scalpel. And so I want people to know that they've had all the reasonable decisions or all the reasonable options for their condition so that they can make a decision on what's best for them.

Dr. Ariana

Awesome. So I know that you have been really successful and you have just opened up a second location. And if you can maybe share a little bit about that experience because really you got to do it from scratch. And so if people are opening up practices, orthobiologic or cash practices from scratch, this really is going to resonate with them. And what I would love for you to share is the decisions, the good decisions that you made, your favorite decisions, and then maybe decisions that seemed good at the time, knowing that you've been doing this for a couple of years and you've been in the business and maybe decisions that seemed good at the time but haven't panned out, if you can maybe share that. And by the way, congratulations on your second location. It's awesome.

Dr. Don

Yeah, we opened the doors, September 5th, so thank you. Yeah, big decision. I've only had one office all these years, so I didn't have a bunch of locations to just start adding orthobiologics. So this was truly a new venture for me. And really the first decision was, what am I trying to be? Am I trying to open up another location where I can be there three days a week and be in my other office two days a week? In other words, am I just trying to spread myself out? Or am I trying to take what I have and bring it to even more people by training clinicians and having, if you want to call it, having it the Texas Orthobiologics way to do orthobiologics and orthopedic surgery? And I opted for the latter because we can only-- and that's the problem we have in the insurance model. We can only do so much. There are only so many hours in the day. But if I could have a clinic open and running at the same time that I'm in another place running the same clinic with people doing the same thing the way that I think it should be done, that was really a force multiplier for me. So that's what I decided. That was decision number one, because from that decision, that means that I need a clinical person, okay? I need somebody who can make diagnoses and do injections, at least the basic things. And deciding who that person is going to be is the next big decision, even before you start thinking about leases and things like that. And so for me, the answer was I knew of a very excited, interested, talented physican's assistant who was relatively in her practice but very skilled. And what it took for me to make that decision was deciding how to best use her if she was going to be independent 90% of the time. And what we decided was that if she could really do the top 10 things that we do in orthobiologics independently, that was more than enough justification to open up a new place. And so she spent a good 4-6 months with me getting trained as an internship, basically, or a fellowship, I guess at that level, as a postgraduate. And that's not the only way to do it. If I had had another friend or person and put out a job hunt for a clinician that was already could do those things, then that would have been another way to solve it. It just happened to be that I knew this person and we had already had conversations before the decision to open up a second location ever happened. So lots of ways to get that clinician. For me, the option was physician's assistant and make sure that she was trained to comfortably not only make diagnoses, but to do the top 10 procedures that we do, which for me covered-- and so far in the first two months, it's covered just about everything that she's seen. There have been a couple of lumbar spine cases I've been involved with and a couple of bone marrow cases we can talk about that I've been involved with also. But your bread and butter, knee injections, elbow, hip, shoulder, foot, and ankle, she can do those. And so that was just--

Dr. Ariana

Yeah. What are your top 10-- so if someone were wanting to say, okay, I want to be sure that I'm at least trained enough in ultrasound-guided orthobiologic injections to hit 80% of the market. But as a physician, what do you think those top 10 injections are?

Dr. Don

So my answer is super specific because it's based on my data biologics data.

Dr. Ariana

Okay.

Dr. Don

If we go into our data biologics registry, we can see literally by numbers what we do. So knee is going to be number one for virtually everybody unless you just say I'm just a knee, elbow surgeon, or something like that. But knee is number one. For me, shoulder is number two. Low back, I think in data biologics is classified as-- it's not lumbar-sacral or maybe it is. But basically low back, which includes SI joint and some other things. And then there's a three or four-way tie between elbow, hip, and I guess a two-way tie between elbow and hip. So the knee and shoulder are far away one and two, back is next. And then hip and elbow would be after that. And then beyond that, you get into the more distal things like the base of the thumb, CMC arthritis. You get into some ankle arthritis.

Dr. Ariana

Got you.

Dr. Don

Yeah.

Dr. Ariana

Yeah. Awesome. So from a business perspective, so you've got your person. What's the next step?

Dr. Don

Yeah. So the next step, once you've decided if this is a place you're going to open up and you're going to split time or if you're going to have someone else, that's number one, then getting that next person, whether you're going to hire someone already established or train them yourselves, to me, that was number two. And then the next you notice this is all staffing at the beginning for me. That was the beginning. And so the next step was how many employees do I need to make a clinic run. In a clinic that's going to be based primarily on regenerative medicine, meaning that for that clinic, I'm not really advertising it as an orthopedic clinic. It becomes obvious because of our website, but it's very different from the advertising I've done over the last 20-something years that I'm a fellowship-trained shoulder surgeon and also do orthobiologics. And looking at my current practice and what we really need, what we decided was we needed a front desk person, I mean,  that's a given. We needed the PA, who I already talked about. And really at the beginning, the only other person we needed was a medical assistant that could draw blood. And so at that clinic, we've got the PA, and I'm not using their names on purpose, but we've got a PA and a medical assistant who can both draw blood. So there are two people that can draw blood. I thought about maybe getting another medical assistant to actually have a dual duty as the receptionist. But you don't want to do that, in my opinion, because they didn't become medical assistants to be receptionists and to be front desk, you know, and vice versa. So we just have three people, and they're there whenever the office is open. All three of them are there, okay?

Dr. Ariana

And you're open full-time?

Dr. Don

Yeah, we're open full-time. That was the whole goal from that first decision, which was I want that to be an independent clinic where people can go and they can walk in if they need to walk in. But it's the same type of concierge practice feel. In fact, it's nicer than my Dallas office. That's three people. That's not very many people. That's three full-time employees to open up a clinic where you can help a lot of people, you know. Then the next step was.-- do you want me to keep going?

Dr. Ariana

Yeah, I want to know all the things. Yes, please.

Dr. Don

The next step was how much space do we need? And again, looking at my office in Dallas that you've been to, I really was given a pod, which was four exam rooms, and that was the way our office building was designed. And so we have four pods, and basically, each partner in the group got their own pod to basically do what they wanted with. And so as you can imagine, about 10, 15 years ago, I took one of my rooms and made it a biology lab. So they thought I was crazy, but I was much more interested in having an in-house way to test things and even just as a study room than as another orthopedic surgery examination room. And so I've been running my practice with three exam rooms for a really long time, so I know that that can be done. And that is with doing procedures in those rooms every day. And so for me, that answer, the answer started to get easier. So I knew I wanted a place big enough to have three exam rooms. I wanted a good-sized lab, so that's four rooms. I don't have a procedure room where I'm currently at and you can get away with that if you're doing procedures in the room using ultrasound and you're not doing anything where you require fluoro. And that just happens to be the way I'm set up. I know many, many, many of our friends use fluoro. Nothing wrong with that. Obviously, that raises your requirements a little bit. You have to get one other room that you've got properly set up for fluoro. And doesn't always mean you need lead-lined and stuff because some of the C-arm and things you don't need protection, but something to at least consider. So for me, with the way my practice was structured, it is three exam rooms, a lab, then we've got a couple of bathrooms, a lobby and reception area, and a break room, okay? So all of that gets put into 1,500 square feet. And you've seen the rooms, they're big rooms and it's quite comfortable.

Dr. Ariana

They're beautiful. Yeah.

Dr. Don

Yeah. So then you just have to figure out what 1,500 square feet costs in your city, and that's going to be your monthly rent. Where I'm at in this new location, it costs me about four grand a month for rent.

Dr. Ariana

Awesome. So what do you think has been the best decision that you're like, oh, man, I'm so glad I did this.

Dr. Don

Yes. So this is going to sound a little one-off, but I invested in some really good procedure beds.

Dr. Ariana

That was going to be my guess, is that those were going to be like, I'm going to [inaudible] that this.

Dr. Don

I'm so happy I did that because--

Dr. Ariana

Can you share with everybody what that is?

Dr. Don

Yeah, for sure. So again, for most of the audience that are in surgical practices, our exam beds in those rooms are usually just flat beds, and they have a little bit of paper on them that we can change out in between patients. And, you know, if we're a little bit fancier, maybe the bed will be adjustable in one way or it'll flex, but they're not really procedure beds in most of our practices that I've ever been to. But once you become a proceduralist, if I'm trying to do injections and keep people comfortable and getting bone marrow and turning people prone, I want a bed much more like you would see in a spa or in a massage parlor or a licensed massage parlor or any of those places where you have a luxury, think, five-star hotel, you go in to get a spa treatment and the bed just adjust to your body.

Dr. Ariana

Yeah.

Dr. Don

It's memory foam.

Dr. Ariana

Yes.

Dr. Don

So that's what I was looking for. And turns out those are not cheap. You know you're looking at about six grand per bed, sometimes more than that. Sometimes more than that. And so I started looking around the internet. Thank goodness we have the internet. A lot of those beds are made overseas, if not all of them, but a lot of them are made overseas. I was able to find a source from a manufacturer that was actually in China and got on the phone. Thank goodness for WhatsApp and emails, but got on the phone with someone who spoke perfect English and described what I was looking for. The biggest thing for me to make sure of was that they understood I only wanted three beds and not 300, okay? Because I didn't want to get that Amex charge.

Dr. Ariana

Right.

Dr. Don

I would love the points, didn't want to have to pay for it. And they're like, no, three is okay. And so they sent the beds. I was able to pick the color of the bed and the color of the cover on top. These beds are almost infinitely adjustable. So I think they're ergonomic, beds go up and down. They flex, the arms go down, and they arrive or they get shipped fully assembled. They get palletized and put on a boat. Takes about a month. You have to plan on six weeks but takes about a month to get to the States and get to you. But they were one-third the price, which is where I was heading with all that.

Dr. Ariana

Yeah.

Dr. Don

That was a huge savings. And, you know, in the back of my mind, I didn't want to have to take any debt out for this new location. That was one of the big ways we were able to save money.

Dr. Ariana

Nice.

Dr. Don

The other big expense is going to be the lab, depending on how complicated your lab needs to be. If you're using kits and things like that, you just need a nice, clean space. If you're doing some other more exotic things, you may need a hood even. And those hoods end up being four or $5,000 for a four-foot hood. You know that I firmly believe we should all have hematology analyzers if we're doing PRP, and probably cell counters if we're doing cellular procedures. And those aren't cheap, but those also need a dedicated space in the lab where they're clean and you can keep them calibrated and up to date.

Dr. Ariana

Awesome. So do you think it is a reasonable thought process to be able to open an orthobiologics clinic on your own? Is that something that's viable? Is it an exorbitant cost? Is it not too bad? What does that-- if I wanted to go all in and open up a clinic, what would be my time frame and what would be my approximate investment?

Dr. Don

Well, so where do we leave off? With that 1,500-square-foot lease space that I was looking for, we probably looked at-- you know, I gave that specific list of criteria. I wanted three exam rooms, a lab, a restroom, a break room, and a reception lobby in about 1,500 square feet. I did not want to have to remodel a place. So we were preferentially looking at medical sites, which lowered the cost of entry significantly. In fact, the place that we ended up at, we didn't have to change a thing. The rooms were already set the way they were. It was perfect. And it was worth taking that extra week or two to find that or at least find some place where you don't have to make wholesale changes. The other thing in the lease space that will help you, at least for me at this stage in my career, I know I'm not always right. I try and set up my life so I can be wrong 80% of the time and still do okay. I did not want to sign a five-year lease. I didn't even want to sign a three-year lease. The shorter the amount of time you're willing to put your name on the lease, the harder it is to get the landlord to agree. And so here's what I did. The broker is not super happy that they're getting this handed to them either, but they work for you. I said I wanted a one-year lease and I wanted to be able to renew it, but I didn't want to be on the hook for more than a year just in case orthobiologics completely went away for some reason, you know. So I said I'll do a one-year lease, but tell the landlord that they don't have to give me any money for the office. Whatever we need to do, I'll do it myself. So I put in the floors, which cost me, if we're keeping track, cost me like $6,000 to put in new floors. The landlord was already going to paint the walls and things, so that was not an issue. And like I said, what kept my cost down there was not having to do new walls or plumbing or anything else, just the floors. But I didn't ask the landlord for any finish-out money. So everything else I did was just on me. And so once they understood that they were much more willing to do the shorter lease. And the final wrinkle I threw at them was I did not want to personally guarantee it. And so that's something that everyone may not be able to do if you have no track record at all. But my company, Texas Orthobiologics had a pretty long track record in the area. Business and personal credit were good. And so they agreed to do this one-year lease with renewals with no personal guarantee. And so that was the crux of what I was really looking for financially when getting on the hook for something, because that potentially if you sign a three-year lease and you're on the hook even at four grand a month, right? That's 150 grand. And we can all be wrong. And not wrong about orthobiologics, but about location, staffing, about the population around that area, you know. All sorts of things can happen. So that's why I wanted to minimize my risk there and still have the ability to re-up in the same location.

Dr. Ariana

Okay. What are we talking about like an outlay? If I have to save up, let's say I want to open a second location. I'm like, okay, I got to save up for this 1,500-square-foot place, and I'm going to get my new beds from madeinchina.com, and I'm going to love this. This is going to be amazing. I already have all of the other things. What are we looking at?

Dr. Don

Well, you know me. I'd rather estimate high and have everyone come in after it. I'll say 50,000. And the reason is you have to be able to cover your salaries.

Dr. Ariana

Yeah.

Dr. Don

You've got to be able to cover your salaries and 50, if not even a little bit more. But it depends on how you can utilize or who you put in that position as the lead clinician in that new office.

Dr. Ariana

Yeah.

Dr. Don

So I was very specific. In our meetings, I said, look, this is a regenerative medicine clinic. We're not an urgent care. I could have very easily gotten busy and had revenue from day one if we just accepted walk-ins and phone calls from people that say, hey, I sprained my ankle the other day. Can I come in? Or, my kid got hurt in football on Friday. Can I come in Monday? We could have easily probably generated many thousands of dollars in the very first month, but I didn't want to do that, and so we didn't. It's a little bit hard, but we planned for it upfront. And so that's why I'm giving you a higher number.

Dr. Ariana

Sure. Yeah.

Dr. Don

If somebody wants to be a little bit more open in terms of how the clinic runs, in terms of the indications in the patient population, they may cash flow a lot quicker. In my ideal world, we wouldn't have any insurance at that location, okay? But sometimes we still take insurance for that first visit, and that's part of the reason why we had to be a little bit careful. But 50,000 includes the finish out, it includes some salary for-- I just budgeted in for two months. I was confident enough that we would be busy because we had overflow from the Dallas location.

Dr. Ariana

Sure. Awesome.

Dr. Don

Yeah, I knew that if they just saw people that we had taken care of in Dallas if they just picked off the people that were close to the new office that they would be paying for themselves.

Dr. Ariana

Okay. All right. And then from a build-out time frame like six weeks, three months, what do you think? If I find a place tomorrow and it was pretty reasonably set up, what do you think? A time frame.

Dr. Don

Less than a month.

Dr. Ariana

Okay. So we can put the beds. The awesome beds.

Dr. Don

Yeah. I mean, if you pick the flooring that's basically in stock and doesn't have to be part of a supply chain problem, then that can happen in a day or two, you know. 1,500 square feet isn't very large in terms of putting in new floors. They got that knocked up in a day, a day and a half at the most.

Dr. Ariana

Awesome. So tell me this. You know, you are so confident in orthobiologics. You're like, heck, I'm going to open another practice. It's going to be amazing. What do you think have been the main benefits that you've seen since integrating orthobiologics into your orthopedic practice? What do you think it will like why should we do this? Why should we advocate orthopedic surgeons to integrate orthobiologics into their practice? What do you think the benefits are?

Dr. Don

Well, it really goes to where you made the decision to become a doctor, at least for me it does, which was I wanted to help people and I went into orthopedics and even in a more narrow focus into sports medicine because I wanted to keep people active. I wanted people to continue to be active or get back to being active and to keep doing the things they love, which is one of our little bullet points on our website. We keep you doing the things that you love. And surgery is great for doing that if it's a surgical problem. But a lot of times it's not a surgical problem. And that is where we have this treatment gap that we talk about. We can't just keep doing steroid injections and expecting people to be okay. I actually believe this is just a level six opinion that one day, someone will do a study, and we'll be able to figure out how many more people end up in surgery from repetitive steroid injections, and if they hadn't gotten them at all.

Dr. Ariana

Oh, my gosh, you know [inaudible] 

Dr. Don

Nobody wants to know the answer to that. Nobody wants to know the answer to that.

Dr. Ariana

No. How many patients I know? I think back, and I know the literature, and I'm like, oh, my gosh. Just even hip injections, where we know that steroid injections for hip arthritis, for sure, accelerate the path towards total hip. I'm like, oh, my gosh. How many hip injections of steroids have I recommended over the years? And the number is really, unfortunately, really high. And so I'm like, oh, my gosh, I just hastened all of these people to get joint replacements. I'm sure the joint replacement companies are super happy with me. But I was acting from a place of trying to help patients, and I didn't have that tool in my tool belt that was orthobiologics. And so I look back, I'm like, oh boy, I'm pretty sure I hastened a lot of people's arthritis. And I feel horrible about it.

Dr. Don

It doesn't take a large percentage for it to be a huge number because they just had the hip and knee, shoulder society meeting here in the Dallas area. If you've got 4,000 people, surgeons, hip and knee surgeons, and it's just 1% of each of them, that's a huge number, right?

Dr. Ariana

No.

Dr. Don

So for me, that's the promise of is that people in that treatment gap, we now have an option that, at least to this point, we've never shown that it accelerates degenerative conditions, at least in the way that we're doing it currently. We're starting to get more and more evidence for more and more indications that it actually is helping. And in some cases, preventative, and in some cases, it accelerates healing. And in those cases, even where it doesn't accelerate healing, people get back to a functional level that they're happy and don't want surgery.

Dr. Ariana

Well, do you think that it does change that natural history of disease where if we hadn't intervened with orthobiologics, they'd be further down that road? Intervening with orthobiologics changes the natural history. Maybe it just stops the progression. It doesn't cure arthritis or cure it, but it actually changes that trajectory.

Dr. Don

Yeah, I think they're clearly disease-modifying injections. I think that at least in the United States, what we're going to find out one day is that our dose is low. If you really want to be truly disease-modifying or disease-avoiding or the Holy Grail disease-reversing.

Dr. Ariana

Cure.

Dr. Don

Yeah, then especially think about cartilage and things like that and tendinopathies. There's already some work, you know, our keynote speaker last year at our big IOF MAX meeting showed tremendous tendinopathy healing and even tendon tear healing. But the dose was 20 million versus 30,000. Twenty million in his practice, 30,000 in mine. So I think as we get to a higher dose, we're going to figure out that we actually can have even more of an impact than we currently think we're doing, which is great. And so that's why I went into it. I think that the promise for an orthopedic surgeon is if you went into this to help people and to keep them doing the things they love and to return them to function and to keep them healthy, this is a no-brainer. I mean, put down the steroid and pick this up, or at least figure out where it makes sense in your own practice.

Dr. Ariana

That you're a call to action. Put down the steroid, just use PRP instead.

Dr. Don

Yeah. And PRP-- we hear a lot about the cost. A lot of the naysayers will talk about its cash pay. These kits are between $150 and $300. We're talking about helping someone for a year, sometimes longer than that.

Dr. Ariana

Right.

Dr. Don

Yeah. So the cost-benefit even there makes sense, even if it's not covered by insurance. If insurance doesn't cover it, then the doctor has to assume some of that additional cost to do all that. And that's why it's more expensive. But we'll see what happens.

Dr. Ariana

Yeah. So a couple of things that I'm wondering about. What do you think going forward is going to be your biggest challenge from a business perspective? Regarding you now have two locations, you're heavily invested in this cash pay model. What do you think is going to be the biggest challenge? And what do you think is going to be the biggest benefit?

Dr. Don

Well, if on the insurance side, things stay as is, then the way the clinics are constructed will be fine because that's what we've planned on. I guess the most disruptive thing that would happen in the near term would be, and I don't see this happening anytime soon, but what if all of the commercial insurance companies said, okay, we will now cover PRP, and they come up with a price without colluding somehow of-- you know, pick a number, $600, $700, whatever it is. So that would just change the model. But that would put us no worse than we are currently with our surgical practice.

Dr. Ariana

Right, totally.

Dr. Don

Probably still in a better situation. We know that TRICare covers PRP for knees and for elbows, and TRICare covers at about a $2,000 price point for one injection. And as long as you meet the criteria and if insurance companies value it that way, which I think is appropriate, then there's no change in the model needed at all.

Dr. Ariana

So what information do you wish you had at the outset of maybe not just your new opening, but reaching back and saying, gosh, if I would have just done this, I'd be further along. Anything or [inaudible] 

Dr. Don

Other than getting to the party a little bit earlier. But I got there pretty early.

Dr. Ariana

Oh, man. You got there pretty dang early. I don't know.

Dr. Don

I should have mentioned, literally concurrently with this interest in PRP was MSK Ultrasound at the exact same time because you need both. And, I mean, they go together. That's peanut butter and jelly, and you can't separate them. So at this point, if someone was just getting started, it's very similar advice to what you would get in other specialties and other fields, right? Find somebody who you think is doing a good job and try and find out how they're doing it and try and emulate them. So fancy way of saying find a mentor, if you can, it's going to be harder to find a mentor in each specific geographic location. But now we have the Internet, we have LinkedIn, we have Facebook, we have these meetings that we have. And so it becomes relatively easier to locate people that you think are good. I know a lot of people will host visitors in town, and that's usually time and money well spent to actually see how a clinic runs that's efficient. And that's one thing. The other thing, as you know, is the medical decision-making. If you're going to incorporate orthobiologics, you've got to think about your medical decision-making about when and how, and always staying mindful of the evidence for what we're doing and what we're offering to patients. So I think that would be the biggest thing would be to try and find mentors sooner, but that's easy.

Dr. Ariana

Yeah. If you were talking to an orthopedic surgeon that was like, yeah, man, this PRP thing seems like a good idea, but I have no idea where to start. What would be the next step?

Dr. Don

So the next step--

Dr. Ariana

And you can go ahead and tell people they should get trained in an ultrasound.

Dr. Don

Yeah. So if you want to do this well and match the best results that are out there, then you've got to hang out at the places where those people are. And that means you have to go to meetings. Now, things are growing, which is fantastic. So just running the list, you've got the interventional orthobiologics foundation, which is about a 200-300% strong nationwide nonprofit organization which has set itself up to provide fellowship and postgraduate level structured training in this exact thing that we're talking about orthobiologics. So not only in the how and the why, but you're also going to meet the who. You're going to meet the people doing it, and those are the people actually teaching. And so I think that's a very valuable organization to join. Within our orthopedic surgery specialties, there's the Biologic Association now, which is an association of nine other subspecialty organizations. And they sponsor some educational curriculum, and they work with some of the others that are interested, like the Interventional Orthobiologics Foundation. In terms of ultrasound training, we have a course obviously that's twice a year. Then we combine regenerative medicine along with live demos and then two days of MSK ultrasound at our "orthosono.com" course.

Dr. Ariana

That's my favorite, by the way. That's where I started out way back in the day. I took that course and it was so helpful to get started. And really, it was a one-stop shop to learn everything you ever wanted and needed to know for integrating ultrasound in your practice. And the tips and tricks are so valuable to just get started. I'm going to plug. I don't get paid, but I'm going to plug. Please take the "orthosono.com" course if you're interested in orthobiologics, you have to have ultrasound guidance in your practice. The OG is also the OG in ultrasound training. Definitely, that's one of those.

Dr. Don

I've taken a lot of courses because you never know where you're going to hear the next pearl, right? Sometimes hearing things from a different perspective actually really sinks in the knowledge. And there are some industry-led courses as well. So some of the ultrasound vendors or the orthobiologic vendors will sponsor courses and they're valuable. So don't forget about those as well. So the point is there's a lot of opportunity now. There really is. And if you're not involved in any of the organizations on LinkedIn, or there are a few Facebook channels but I think LinkedIn for most of us is the predominant way that as professionals we communicate. So there's the Biologic Orthopedic Society, I think it is on LinkedIn. But even just following some of the people like Dr. DeMers or myself on LinkedIn, you'll get exposed to a lot of conversation and very quickly be able to build your contact list on LinkedIn. And into a list that has dozens and dozens of very like-minded orthopedic and orthobiologic clinicians.

Dr. Ariana

Awesome.

Dr. Don

I mean, we learn something every day, if not every week.

Dr. Ariana

Right? I know. It's such a fascinating field. It's growing so fast and evolving so quickly that I think the hardest part is staying abreast of the research that's out there. I keep hearing this like, oh, well, what you're doing is great, but there's no research to it. And so number one, that's not true. There's a growing body of evidence that supports the use of orthobiologics in the musculoskeletal realm of treatment. But ultimately, it's just so exciting. And it's so exciting to be able to take care of your patients who are in that gap, who are not surgical, but not satisfied with where they are and they're still hurting and they're coming to you for solutions. And so this orthobiologics, I do think fills that gap in our treatment algorithm quite nicely.

Dr. Don

Yeah, it's something I've said before, which is as surgeons, we may not understand how that can help our practice now, but your practice by nature will change if people know that you offer non-surgical solutions that can help them. And what I mean by that is you will see patients that you wouldn't otherwise see. I see people now who I think forget that I'm a surgeon. And when I do my little discussion on my little whiteboard, my dry erase board and I put on the far right side that here is surgery. They also, oh, I'm never doing surgery. I didn't want to go see the surgeon. I'm like, well, okay, fair enough. But there's a lot of--

Dr. Ariana

Here I am.

Dr. Don

Yeah, I'm like, but there's a lot of people that, for whatever personal reason, right, cross surgery off the list. And for some people, that's a never, ever doing that thing. And for some people, it's never doing that until I've tried everything else kind of thing. And for some people, it's just because they don't know enough about surgery and you can educate them there too. But for whatever reason, the expansion in your practice won't just be from your surgical patients.

Dr. Ariana

You'll see people into your practice that you would not otherwise see, that you've not been exposed to ever if you've never had anything but steroid shots and surgery as options and anti-inflammatories.

Dr. Ariana

Awesome. So I wanted to thank you so much for sharing your time and your perspective. How can people find you if they want to know more about you and what you do?

Dr. Don

Sure.

Dr. Ariana

Obviously, it's pretty clear. I mean, you're like all over LinkedIn, but can you please tell everybody where they might be able to find you?

Dr. Don

I'm going to send up the bat signal. The website is really easy. It's just Texas Orthobiologics, all spelled out altogether. So "texasorthobiologics.com" is the website, and that'll give you from that one place, you can find us on all of the other social media. But if you want to go to Facebook or to Instagram, if you type in Texas Orthobiologics, or on most of them, if you type in my name, you'll get to our channels. Youtube is something else we should mention. We have a lot of videos and a lot of talks on two YouTube channels. Most of the surgeries are under my name, so under the Don Buford MD channel. But most of the regenerative medicine stuff is under the Texas Orthobiologics channel on YouTube, and all that stuff is free and it's evergreen. It's just sitting there waiting for somebody to click on it and like and subscribe to it. And then, of course, LinkedIn.

Dr. Ariana

All right, everybody. We'll go ahead and go to YouTube. Go subscribe to Don Buford MD and text orthobiologics. Hit the subscribe button.

Dr. Don

Right. I feel like I'm in the video pointing or something.

Dr. Ariana

Right. Do it here. Awesome. Well, thank you so much for your time. This has been "The Business of Orthobiologics". I thank everybody for listening. And until next time, thanks so much.

Dr. Don

Thank you.

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.