BoneChat #140 - Transforming Knee Rehab, Patient Experience, and MedTech Go-to-Market

So, anything you want to talk about, Sheila, Kyle, Eric? It's just— or we can just pass, whatever you guys want to do.

Sure. You know, I just got, I just got off a call with a retired physician who had knee replacement. He happened to buy my product, and, uh, his knee replacement part has gone phenomenal, meaning he's like He's 6 weeks as of last week. Anyways, he's 0 to 131 degrees, doing great. And he was texting me to say, which for the record, retired physicians are the worst customers. They think they have full access to you 24/7. Anyways, but he was complaining about his surgeon. He goes, I feel like a cow being herded. He goes, you see them during literally for 2 seconds to say, yep, you need surgery. Then you say to them like, hey, we're going to do this leg. See you when you wake up. And anyways, we went to the follow-up and he was Just disappointed in the customer service part of it, meaning no questions were answered. He was having some tightness and some clunking and whatever. But anyways, my point is, I— that's probably the 3rd call I've had this week of knee replacement patients saying that the quality of customer service in orthopedic offices, from front office to follow-up visits, is poor. And they feel like, you know, which is interesting because all I've been reading is, you know, surgeons complaining about the reimbursements. Declining coming up. And anyways, just food for thought of like, you know, are they going to actually do more if reimbursement decreases? No. And so I feel like the customer service, I don't see that solving anytime soon. So anyway.

Yeah, it's— cattle is a good acronym. I think it's— you just slide them in, brand them, and get rid of them.

Yeah.

He said the nurse practitioner said, because he had a list of questions, and she goes, I'm going to stop you. His name is Dr. Bruce. She goes, I'm going to stop you, Dr. Bruce. And she goes, is your knee pain better than it was before surgery? And he goes, yeah. And she goes, your range is better than it was before surgery? And he goes, yes. And she goes, it's a win. And it's just so interesting because that is the measure of success for the surgeon. But the patient's measure of success, that is not even that he's successful, but he has questions. He's uncertain. But it is a well-oiled machine. They're just doing surgeries after surgeries, but they're not addressing the patient's concerns. And I'm going to dive deeper into the patient-reported outcomes and patient satisfaction. What are those measurement outcomes looking like? Because if it's the patient's subjective report and they don't feel heard, I don't care how great of a surgeon you are. I don't care how great the range of motion is because this guy is check, check. He is unhappy with his orthopedic practice. Interesting.

Yeah, I read a study years ago that it was about general surgery. But it basically said the, the, the score that you give the healthcare is has nothing to do with the outcome of the surgery. It's all bedside manner. You know, the doctor can screw you up so bad in surgery, but he was so nice, and he held my hand, and he took extra time. I mean, it's just, it is crazy how people. equate friendliness with good service.

Now, I fully agree. And with the changes happening, I don't— there's no surgeons that I've been talking to that are revamping their prehab part, like meaning the ramp-up to the surgery. There's not a lot that are looking to see what can they do to make the customer feel heard and seen and validated and whatever. And I just think that's a big piece of the pie, which obviously I'm trying to solve. But You're right, Tiger. Like, they— it's about the emotional connection and feeling like they understand me instead of, you're one knee today out of 8 that I'm gonna see today, you know, and I saw 8 yesterday and I saw 40 last month. Like, you know, this is the person's one and only, hopefully. Maybe they're gonna have 2, but I feel like surgeons are just so good and it's such a well-oiled machine, they're forgetting this is a life-changing decision. It's an elective procedure. They didn't make it lightly. And yet we're just kind of like, let's go, let's go. Like, we'll see you at 6 AM tomorrow, you know. So anyway. Yeah.

Yeah.

Well, we're about to, we're gonna have this, there's a famous surgeon in Atlanta that's doing 12 total knees a day and he's trying to push it to 16. And we're gonna have him on Bone Chat one day. He's just too busy, but, uh, for obvious reasons. But we'll find a Thursday and that'll be fascinating. And that we have Bone Chat members that have been in his surgery and he, it's not anything fancy. He just, it's, like efficiency. It's like a factory automation efficiency. So that'll be interesting. Kyle, what's on your mind? You're deep in thought.

I don't think Sheila's pointed out something that is going to change or get easier or get better.

I think you're right.

You know, I've seen Uh, the— I guess it's coming, coming at it from a different point of view. I see, you know, my, my relatives that are getting older and, you know, getting hips and knees, live in Florida. You know, I always tell them, I say, hey, call me beforehand. Let me know who the surgeon is. Let me, let me check this out for you and that kind of thing. And a lot of times I'll check them out and they're just fine. But other times, you know, sales rep or whoever I'm talking to will say, you know, you may want to get a second opinion. So I pass it along to my relative and they say, oh no, this guy is so nice, so nice, and their staff treats me well, and they go and get a shitty knee.

Let me add to that, Eric, that instead of just doing the research on the surgeon, I'm telling you as a PT, we can undo the best surgeon's work by being overly aggressive or not listening to the patient or pushing, you know, the treatments that we like to to do. So FYI, do just as much research in the therapy, um, protocol that surgeons have afterwards, because I'm telling you, most surgeons are pretty good. They know what they're doing. These hip and knees are— they're doing a good job. So even an average, you know, orthopedic surgeon with average results can, again, have superior recoveries if the therapy is done right. And I'm just telling you, the more I dig, the therapy is the piece that determines a really good recovery or doesn't, it's bad.

Yep.

And I heard you actually have passed that along to— date myself again. I got a call from someone there. My 40th high school reunion is coming up and everyone there, they're all starting to fall apart and whatnot. But a couple of people that I talked to had just had some surgeries. One had shoulder and one had a knee. And I told them, I said, hey, babe, Very close attention to this PT thing, and you know it's it's it's your PT. It's not it's not theirs. So I have passed that along. So I have heard.

Good. Yeah, it really matters. Yeah, we Sheila and I talked offline, and and yeah yeah, I don't usually say this, but always I. Consider orthopedic surgeons to be like super high specialized auto mechanics. Like if you need a if you need a transmission, these guys know how to rebuild a transmission really really good. But they're they're just gonna do the transaction and then you're on your own for the most part. And they don't see the holistic. Patient, like, and I think they do. I think it's, it's better in Europe. You know, they, they seem to really, they have their systems are better. You know, people that do, you know, tourism, they do surgical tourism that go to, you know, Taiwan or, you know, I don't know, South America, Costa Rica. They always say, man, you, it's like staying in a luxury hotel and there's Nurses checking on me every hour, and it's just— it's different, you know. Um, hey Raymond, we're just doing open discussion today. Anything on your mind?

Um, actually, usually there is, but I've been so focused on other things that you caught me cold.

That's okay.

Give me a minute.

So you're always raising money.

Well, I'm trying. Maybe not always raising. I'm good at trying. How's that?

Well, everybody's in the same boat.

So I just fielded a response from an entity that said, yeah, we got burned twice in spine recently. So we're going to pass. And so other people's past history is affecting other opportunities. So I guess my response is, yeah, well, I didn't say this. I'm going to privately say this. I'd like to, I hope, not in an arrogant way, that I could prove the contrarian view is the one that will be— that's certainly our objective. You know, I do agree. I don't want to sound like I'm smarter or better than anybody else that's failed in the past. I'm just saying we're working hard to succeed.

Yeah.

Well, the messaging is really important. You know, you got to be, you have to be unique. You have to be different. You have to have a new category that really, really helps. But if you just, they lump everybody, investors lump you in, oh, another spine company, another joint company, another trauma company. It's easy to get lumped in like that. You know, Alyssa's not here today, but you know, Alyssa is trying to, you know, I mean, she's selling a pedicle screw, right? But she's positioned it as a therapeutic device, therapeutic hardware. It's hardware that allows you to put in stem cells or what, PRP or whatever the heck you wanna put in. Just happens to be hardware, but the hardware's not the thing. It's the, it's a delivery mechanism. She's a, Delivery mechanism startup. And it took her, it took her a long time to find that. And I like it.

Yeah. Positioning, characterizing, that's a good point.

Yeah, the story, you know, you got to get the 30-second pitch down, you know, where, what makes you different. It's so hard. Yeah, we've talked— go ahead.

I was gonna say, I have a question for you guys. You guys have a different perspective, different, um, you know, life experiences, work experiences. So for someone like— this is totally self-serving— for someone who only looks at the pre-journey for the customer, for the patient, and the post-op, you know, I— the only thing I'm missing is the knee replacement, the day of the surgery. Like, I do everything before and everything after. From physical, home, mind. Like, it's, it's not just the new— like, to me, you know, the more expectations that are set, the more buy-in that you have. And like Tiger said, the more they like me, the program, the trustworthiness. But my question is, who is my ideal? Who is out there saying, oh no, the reimbursement changes? Oh no, what Medicare is doing? Oh no, how are we going to differentiate and do something different? Like, it's not large ortho. They're kind of like— You know, I feel like they still don't think that it's going to impact them. They think that the surgeons who've always used Stryker are going to keep doing it. And so who is going to tell the surgeons which programs or what devices they're going to use? Is it, is it the private equity firms that own them? Is it the, the, the— like, who do you think is the person looking at a differentiator or a way to monetize something or to even I mean, Dennis and Mark were on a couple weeks ago talking about this joint preservation, and to me, that's fantastic. I love that. But large ortho makes money when people have surgery, right? So I think it's great what they're doing, but I feel like there's also a lot of people that don't want joint preservation per se. But I'm on, I'm on their side. But who do you think is the— who is looking for a solution to target the customer to make sure that the customer in the 90-day episode Does really well, has the least amount of complications, readmission rates, highest satisfaction. Who do you think that is? I don't think it's the surgeon. The surgeon just wants to do surgery, you know.

Well, insurance companies got to be in there somewhere. You know, we've had, we've had 2 hospital administrators on BoneChat, and they've talked about how hospitals are now giant businesses. They're, they're, they're not private equity. Some of them are private equity, but they act like private equity. So all they're doing is looking for more efficiencies all the time. How do we use the OR faster? How do we, Yeah. you know, how do we attract more patients, you know, in our metro area? You know, and then you're right. Big the big ortho is they're all word. They they they want to capture the business with contracts and robots that nobody can ever get out of, and that's their MO.

Well, may I? I don't know whether this is very intelligent. You're way more familiar with what you're talking about than I am, but and maybe this is. Old school. But I do think surgeons, I mean, think about it this way. There are a lot of patients that walk out away from a surgeon that had potentially said, hey, you need a knee replacement, can I schedule you for surgery? And that patient's gonna say, you know, I don't like the way you treated me or your staff scheduled my appointment. I'm gonna go down the street because— Bedside manner, essentially. And so the day of the surgery, whether the surgeon comes in and talks to the patient, what kind of experience that has, whether the patient is like at a knee replacement. I speak from experience. My wife has had 2. And so it was a big deal to her, very positively, that she got in or showed up at I don't know, 1 o'clock in the afternoon, was out by 3:30. And so she goes around, tells all her friends, hey, if you get Dr. So-and-so, you're gonna get in there at 1 o'clock and out by 3:30. It was so much more pleasant than the first knee where I went into the hospital. And so that either drums up business or not. I don't know if that answers your question, but I've seen other patients say, I didn't like the way he treated me. I'm going down to the other orthopedic institute down the road. And so that matters to the— I mean, the business of that surgeon.

Yeah. Does that surgeon, though, your wife's surgeon, the one that she loved, how much time did he spend talking to her about the recovery afterwards? Like what her— you know, like, did she love the therapy afterwards? She loved the surgeon. Did she love the therapy afterwards? Well, um, was that after the—

there are 2 questions you're asking. One is unfair because That particular surgeon knows that I designed her knee. And so I get extra time with him and he's very patient and tolerant. And so I—

You got the VIP treatment.

Yeah, that's— so I'm not a good answer. You're right. How they— how much time they spend, because clinic, they're trying to cram as many patients in in a day. Yeah, that makes a difference. As far as the PT, totally disconnected.

I know.

And all about whether the PT person is any good or not in their bedside manner and whether— and there's a wild wide variation in what they direct her to do. She likes some, she didn't like others, how far the drive was.

Yeah.

Things like that. But it's— there seems to be no connection between what the PT is observing and/or doing and with the orthopedic surgeon, because it's just maybe that's an avenue for you.

Sheila said it last time, it's silos. They don't even talk to each other.

Yeah, I think I remember that you said that, and I agree.

Well, and even when they don't think it's a silo, I just talked to a surgeon in Nashville. They have their ambulatory surgery center and therapy is on floor 3, right? So they own their own therapy. And his thing was like, Talk to, you know, the director there. I mean, our patients have great results. Well, you know, that's what he said to me, the surgeon. He's like, we get great results. So when I asked the director, I'm like, hey, tell me what your average, you know, uh, by 2 weeks, what's the average range of motion for your patients, right? Well below what I think is, is, is good results. But I can't say that to this director, right? And I can't go back to the surgeon because he trusts this guy who's been with him for like 8 years since they opened. And so again, I literally ran into a wall because the surgeon's not ready to hear that Dave is not that great, and Dave thinks his results are great because he hasn't seen anything otherwise. And so, and Dave has an incentive for people to come in 3 times a week. Now the funny thing is the surgeon didn't even know that Dave turns away 58% of this surgeon's referrals because they're too busy. So it's so funny when I say silos, even when they own their own PT clinic, even when they're in the same building, they still don't know what the left hand and right Right hand are doing. So I just found it interesting that this surgeon thinks his PT is the gospel and his results are substandard based on everything that I'm seeing. And like I said, and I can't be the one that's the messenger because they love the relationship, so it's a dead end. But, and the customer doesn't even know, the patient doesn't even know that they're getting substandard results because surgeon is telling them to go to PT, you know, floor up. Anyways, my point is It's great that Raymond's wife probably got really good stuff, but I will tell you, even though the surgeon was great, the PTs, the higher-educated PTs, the doctorates that want to be called doctor, you know, and all the certifications, you know, to me, it's square peg, square hole. So, if they're orthopedic therapists, they only do orthopedic-type things. If they're manually certified, they only do manual. If they're into the cupping, and the scraping, and the needling, then that's what your knee is going to get. There is no standardization. It's What am I good at doing? It's like getting a carpenter. If they're good at this kind of woodwork, that's all you get. And I feel like, you know, you— Raymond said it, you found a surgeon, or Eric said it, you find a surgeon that's really good at knees, but you can't find a PT that's really good at knees. And even if you did, is it sports medicine knees? Is it athlete knees? Or is it chronic knee OA knees? Very, very, very different. So all this time and effort to pick the surgeon. All the time and effort, and then you go and get, in my opinion, substandard recovery. And the old model was, fine, come back in 8 weeks and we'll do a manipulation. Fine, that didn't work, come back in about 4 months, we'll do some scar tissue. Fine, that didn't work, we're gonna send you and get a revision in about 2 years. And the whole time the patient is just suffering and no one says, why did they fail? And Tiger sent me a message, or I read his recent email about the high revision rates. There is no incentive for them to reduce those, right? It's frustrating for me, like, because I don't talk to the surgeons and I don't talk to large ortho. I only talk to the spouses and the actual patient. So frustrating for me. Like, my PT pushed me so hard, my knee swelled up. The doctor says I have to go 3 times a week. If I don't go on my follow-up, he's gonna blame me. Oh, that's awful.

Now again, I'm speaking With not enough knowledge, but I thought the whole PROMs, patient-reported outcome measures, was intended to address the frustration that you're trying to convey.

Yeah.

Now, maybe this is none of my business because it's your business. What is it you're— or how do you plan to monetize this problem that you're going to solve? First, you got to solve it. Maybe you already have, but then how do you monetize it?

Oh, this is the million-dollar question. I have solved it, meaning I have solved it in the essence of I've created a program and a device that if the patient utilizes at home, they are going to have improved satisfaction, improved recovery, improved outcomes, and decreased complications. That's— I've proven it through some research. There's more research being done in Australia and just talking to thousands and thousands of knee patients who have used this. Okay, but monetizing it is the problem right now. I'm just direct-to-consumer. That's like 95% of my business is direct-to-consumer and easy peasy. I understand the patient. So anyone willing to pay the cash and do the work reaps the benefits of my program. But to really scale my business, I have to find B2B, and I haven't figured out how to monetize it for the surgeon's office or for the hospital center because nobody wants to absorb the cost.

So, can you share your screen?

Do you—

can you show a website or a slide deck or something that, uh, So we can better understand. I've seen her website before. It's the— when the device is so simple, it's so simple that you're gonna go, this, this can't possibly work.

But it is ridiculously simple. Okay. I want you guys to be prepared to be underwhelmed. Are you ready? Like, listen, they say expectations is all source of disappointment. So I'm lowering the expectation. Here we go. Tell me when you can see it.

There it is. Okay.

So super simple PVC pool noodle, everything. But the problem— sorry, the benefit is these pads mimic where I would put my hands to create torque for flexion. And the pad behind the knee causes a slight distraction. Okay. So there's a mobilization happening, which is a more comfortable stretch than without the pad. And I'm redoing my landing page. So just disregard this, but hold on.

Just, you know, yeah.

So again, um, extension videos being watched, timers showing you how to do it like old school Jane Fonda. Over here to the right, again, I'm telling you why you're doing it. To the left, I'm showing you how to do it. I'm explaining where you're feeling the pain. I'm telling you what pain you're feeling if you're 2 weeks out versus 8 weeks out. I'm explaining tissue pain versus possibly, uh, pain neuroscience and And fear avoidance. So, I mean, it's, it's like flexion, extension, it's strengthening, it's isometrics, it's quads, it's muscle energy techniques. Um, it's not rocket science. I literally just created a device that mimics my hands because we all know that what they do 7 days a week trumps what they do twice a week in the clinic. And add on top of that a PT who's overly aggressive, right? They are not—

How's it customized per patient?

Well, the interesting thing is it's subjective. I'm like, I want you to push until you get a rating of this, right? So it's all individualized. And as the patient gains range, the angle of the device changes. The device pads move closer as their range improves. So it's really, again, it's how I would change the position on my hands on their legs. The pads move up and down. And it's literally based on torque and force. An angle of hip, knee, and ankle. It's— there is like, literally, I can have them do isometrics. I can have them do end-range knee extension. I can have them do like, you know, sustained stretching. I can have them kicking in the bottom pad and pulling back. Like, all the techniques used in Go Knee are not passive exercises. Passive exercises do not allow you to go up and down stairs. Only— so even this, this device, as the person gains flexion, They now start doing the exercises in their newly gained flexion range of motion. So it's called progressive angular isometric loading. So if your knee bends to here, you're exercising here. If your knee bends to here, you're exercising here. If your knee bends to here, you're constantly gaining active range, which is why, like I said, 131 degrees he was at by 4 weeks. He owned 131 degrees. It wasn't the PT with pushing and exertion got me to 131. And I can get to 118. That's horrible if the PT has to apply so much force to gain an extra 10-12 degrees. Your body doesn't even own that range. So all I did was take— give the ownership, which again, I have no compliance issues. Surgeons are worried about patients not being compliant in these passive range of motion outcome measures, the PROM things. They're worried that patients aren't going to be compliant. They're worried that, you know, and now they're going to be measured based on the patient not doing their exercise at home. I think it's because they're given terrible exercises that cause increased swelling responses in the body. So, without boring the fit—

So, when, when a D2C customer buys this, what do they get? They get the, they get the little PVC thing and then they get a video. Is it a personalized video or—

They get a one-page. So, the box is like 6 by 6 by 36. It weighs 4 pounds and there's one piece of paper in there. And that one piece of paper says, go to this website, this link, and it literally says step 1, you know, I'll show you. It says, you know, step 1, hey, let's put the device together, which it's like popped together like Lego, you know, and then it says let's go into, you know, step 2, which is, you know, and again, it's a recipe that PTs change all the time. So even when patients have a goni, they— the PTs will be like, your extension is good, let's skip that one. Well, it's a recipe. You can't not add salt and expect the outcome to get. So, it's like you put your Goni together. Can you still see my screen?

Yeah, yeah.

You know, so it's like, let's put it together, 1.5 minutes, no, whatever, you know. And then, it's like, all right, let's get started. Like, let's get your knee, you know, to exercise. And the funny thing is I have even like a skip intro kind of like Netflix. Can you see that skip intro? You know, but initially, I tell them that, you know, hey, watch the intro. It's going to provide the education to why you're doing what you're doing and why it You know, and I explain it's a 2-minute stretch. Let me tell you why you're doing a 2-minute stretch. 30 seconds doesn't do X, Y, and Z. You know, 45 seconds doesn't do X, Y, and Z. And so, like, it'll split out into, like, step 1, let's do that. All right, let's increase your knee bending. Let's do some stretching. Let's do some strengthening. Like, it's just a program that sits there and guides them through everything that needs to happen in order for them to have the— it's not rocket science. If you increase— if you reduce pain, reduce swelling, and increase range of motion, Everything else falls into place. PTs are spending too much time doing stuff that doesn't matter.

So why do you— so you can either throw fuel on the DTC, sell more to consumers, or you can try to crack the code on B2B.

Yeah.

The way to crack the code on B2B is you have to find the incentives, you know, at the hospital.

Yeah.

Or Medicare. You gotta find, you gotta find the incentives.

Honestly, that's what I was asking. Who has the incentive to want to do this? You know, and again, I'm— I am not biased. I'm not flawed. I'm naive. There's the word. I am naive in understanding what motivates each layer above the patient. I understand the patient's motivators, but after that, I'm guessing. And when you guess, You can't.

Man.

That's my problem. And with value-based care, with more home-based stuff, with less healthcare touchpoints, you know, the more engaged consumer, younger knee replacement patients, like these are all like, go knee, check, check, check, check, check, right? They're searching online like, hey, how do I prepare for knee replacement? Because they're not getting it from their surgeon's office. You know, hey, what can I do at home? You know, some of them can't afford their PT copays. And like Raymond said, like the drive, what if it's a 30-minute drive? That's terrible. You know, um, what if you're being treated in a group?

I hate to say this, but you may— I mean, you may— you— the United States may not be the best market for you.

I have had more traction in Canada and Australia, the UK.

Um, yeah, I think in the UK, you— I mean, I've been to the UK a bunch of times and they They— the government pays for everything, and there's a value. Every citizen has a value from birth to death that they try to keep you under that number.

Yep.

With all your orthopedic problems. Yeah. So if they— if you can prevent reoperations, re— you know, readmission, infections, you know, they will— they will get real serious about that product or service.

Well, and not only the things you mentioned, also they have a shortage of Physiotherapists to do the care. They have a shortage of surgeons to do the things. Like, there's a backload of all these things.

It's—

I'm from Canada, and so I understand the Canada system. My problem is, does anybody here have a phone number to the person that is a decision maker in the government system that would consider this? Because the, the consumer— my dad lives in Canada— his thing is the government pays. I, I give 50% of my income for the government to provide me socialized medicine. I'm not buying a cash product, right? I mean, I'm generalizing, but so they think that government should provide everything that they need, but it's just not the true thing. But you're right. I mean, the government is in alignment with me. Less customer touchpoints, less healthcare involvement, get the patient as better as fast as possible. The problem is the US does 10 times the many knee replacements as Canada and like 20 times as many as Australia.

Yeah.

It is my biggest market, but—

Yeah, it's a giant market, but it's a Wild West here. No, and it's siloed. So though my— I had experience at a spine company called Ellipse Technologies, and we, we got the NICE approval in the UK. Man, that was a game changer. Uh, NICE, I forgot what it stands for. National something care economics. So anyway, You, you can just Google it. But once you get the NICE approval for your product, you ever— they— every physician in the country has to use your product. They don't have a choice. The government mandates they have to use your product. And if they wanna use something else, they have to fill out a ridiculous amount of paperwork. So NICE is like, and we spent, honey, this is, We spent $100,000 doing economic analysis, and we sent it to the UK government, and they— we got the NICE approval like a year later. And so they care. They really care about how much each patient has cost.

Yeah.

You know, in their lifetime. In the US, we don't care.

We don't care.

We don't care. Yeah, Raymond.

2 questions, and this may be something you are— I'm sure you've already thought about it. First, roughly how much do you charge for this?

$399.

Okay. And then number 2, do you have a patent on it?

I do. A utility patent.

Just in the US?

And Canada. North America.

And is it adequately strong to keep a Chinese manufacturer from doing something similar and basically getting around your patent?

Probably not.

Yeah, that can be off the record. But the, the reason I bring that up is I don't know if just marketing it, marketing it direct to consumer on Amazon, because there are so many You don't think so?

No, I don't do it on Amazon. I haven't done it on Amazon.

Yeah, but that's what I'm suggesting. In other words, direct to consumer. I don't know if that's a great idea at that price point or the risk that China is going to come in and just copy you because as soon as they see it on Amazon, they'll just do the same thing, I would guess. I don't know. Now, the only other thought that comes is totally opposite that. And I may have mentioned this before, and Tiger knows him, and that's Dan Justin. Dan was promoting a boot about, I don't know, 5 years ago that was pre-surgery for adjusting your gait and, or at least extending when you needed a knee replacement, I guess, by offloading the medial condyle. And What was— at first I'm like, yeah, that'll never fly. But the reason why it at least had merit— I don't know what happened to it though— is he got some kind of reimbursement code that was amazing. And it was a way for— getting back to Tiger's point, incentivization— the, the, the, the Knee surgeon was able to monetize whatever percentage of that reimbursement, and then it became really attractive. But why it never flew, I don't know. You'd have to check with Dan and how he got that approval. Do you know, Tiger, how he got some kind of reimbursement?

I don't.

Code.

But he there's another product that came out of Israel called Apos. They're, uh, they look like goofy shoes, but they realign your knee. And it's the same thing that Dan was doing. And I don't— I'm gonna put it in the chat here. It's called Athos Health. You should— I would, I would tell Sheila to look at their business model because I don't know if they ever cracked the code in the US, but they've, they've done really well outside the US. And I think it's a prehab thing. More than anything else.

Yeah. And so if, what, however he, Dan or this other company got the reimbursement, that seems like the pathway you'd want to take. Again, you'd have to get ahold of Dan. Do you know Dan, Sheila, or?

I don't, I don't. But I'm going to look these up.

Yeah, I'm going to put Dan's email address maybe. Yeah, I'll put, I can, I'll have to look it up, but I'm going to put first, I'm going to put his LinkedIn in here. For everybody. Dan is a prolific device inventor. He's got, I think, 150 patents now.

And wow.

In orthopedics and spine.

And I don't want any more. I'll be honest with you. I'm just telling you. And let me, let me also say, Raymond, it's— I haven't gone the insurance route. I talked to Medicare specialists, early on. And the ones I talked to, multiple ones and large companies that do this, they said that because— and again, nobody wants to be— I don't want to be a product in its own category. I feel like I— that is not— it doesn't sound— I thought it was great initially, but it's a terrible category to be in because then nobody knows what to do with it. Nobody knows how to cost it or price it out. So these Medicare specialists told me that they would literally piggyback off another CPT code or HCPCS code, and the reimbursement would be like pennies, like maybe $27, because it looked like a knee straightening, um, device that they already had. And for me to explain that this was so different, but it didn't match anything else that they had, and to create a brand new code was— they were like, you're going to spend years and you're going to spend a ton of money, and then you're going to be at the, the mercy of what they dictate to be the reimbursement code for that, and then that's it. And I was like, okay. So, and I will say that I've now changed. 5 years ago it was just a product, you know, now it's morphed into a program. It's an educational series. It's, you know, it's all of it. It's, it's a fully servicing knee program that, you know, starts months before and goes to how to kneel after your knee replacement surgery, you know, months out. So I feel like that's my protection from China. I've had people, you know, knock that off and actually reach out to me and be like, oh my God, I built your product. I'm so sorry. I'm embarrassed to tell you, but I don't know how to use it.

Right.

And it's like, okay, great. Let me charge you $399 and you can use the one you have and I'll tell you how to use it. But I realized my expertise, my knowledge of the chronic knee OA patients is my secret sauce. The device is just an avenue for me to execute that knowledge. Meaning even if I gave it to your wife tomorrow and handed it to her, she wouldn't know exactly what to do with it. And she might figure one or two of the exercises, But she really wouldn't understand how many reps, how long, what offsets scar tissue, what activates the quad, what disengages the hamstring to elongate. That's my expertise, and I've reciprocated it. Right?

Okay. First off, Tiger, that's an old email. And so I feel more comfortable if, Sheila, you provide me with your email address. And I'll send Dan an email. I don't necessarily have Dan's permission to broadcast his email address publicly, right? But I'll be happy to send Dan an email with you copied.

Yeah, I really appreciate that. I mean, any help— again, I'm not pretending to understand the industry, and I'm definitely not pretending to understand pain points. I mean, the more people I talk to, the more different pain points I hear. Um, the positive is, no matter what the pain point I hear, I, I can find how Goni can be a possible solution for that pain point. But I haven't figured out how to monetize it, which is what Raymond has nailed on the head. How does somebody make money off of it?

Why don't you sell— why don't you sell an hour of consulting to the patient directly?

Oh, no, I can do that easy peasy. I'll tell you, but let me also tell you, like, that's time, right? Like, I can, I can wake up in the morning and have gonii sales, and you're getting $399, and that's fantastic. So I really don't want to get into it because you say 15 minutes, you say 30 minutes, these people like to talk for an hour and a half, and I love to do it. I have a hard time setting the boundary because I am missing patient care. Um, you know, I'm actually doing some patient care next week just because I miss in-person patient care so bad. So My healthcare hat is always on there sometime. And so, I have not done the consultation because I feel like it would take time away from me trying to figure out how to find the right surgeon or the right surgical institution or the right hospital or the right healthcare entity. I feel like that's the best use of my time is to figure that out. I just haven't figured it out.

Yeah, you got to—

Oh, I just found a surgeon in Texas. She does concierge orthopedics. So she's doing only cash. She's got, you know, different tiers, and I love it. I mean, she just reached out and she was like, hey, I don't want them to go to PT for the first 4 weeks. Is your program something that can replace that? I'm like, 100% yes, you know. So her and I went back and forth. She looked at my prehab program, I mean, in detail. She was like, can you eliminate that part, but I'm going to use my this part? And we, we customized it to her patients and what she's offering, but I didn't have to figure out the monetization because she's like, I'm including it in my top two tiers. So they get it because she's included it in her fee structure.

That's a business model is to partner with the concierge services.

Yes.

Yeah. And we're we're gonna on Bone Chat we're gonna have Kinematic on in September, and they they're killing it. Yeah. Mostly doing hip hip concierge. They they just partnered with Whoop. You know, the— I mean, they're, they're going before surgery, surgery, after surgery.

Yeah, well, that was the easiest B2B I've ever had, but that's because she found me, you know, and then had her COO reach out and be like, hey, she wants to know everything you do in your program, you know. And then I barely had to tweak what I needed to do to make her happy. I think we had an argument about ice versus heat and when to use what. I presented her research and she was like, did not know. I'm like, perfect. So I mean, that's awesome. And so my plan is that's just happening now, so I will try to see if I can replicate that, you know, 3 to 6 months and continue to keep doing that. But that's been the easiest because I didn't have to figure out who was going to pay for it.

Yeah, yeah. I like the concierge will find the concierge services, find the patients for you. That's the hard part. And then if they could be— if Go Knee is one of the tools that they can recommend, and you can just pass through the— that sounds great.

Yeah. That was, that was, that was a win for me a couple weeks ago.

So, all right, let's shift gears. So anything else? Kyle, when are you coming out of the closet with your, your new company?

It's—

I can't wait to see.

I don't know, maybe the end of the year is when.

Last time we talked, you're working on 3 things and one Which one is the most interesting of the 3?

Oh, one's further along. We'll have some sort of exit arrangement in the next 6 months that we'll finalize.

It's—

the arrangement's underway, so that one's cool. I'll look forward to telling you guys about that. And then— but I might not be able to because I might just be doing it again and again with the same partner. So we'll see. We'll see how much I can share. But in the next 6 months, we'll, we'll kind of move through that program. And then, um, Kind of side hustle and a couple other things, um, that I want to try and look at in a similar capacity. I just like thinking up new stuff.

Yeah, yeah, there's like— there's endless ideas. The hard part is just picking, testing the idea.

Yeah, well, and I— but I also, I, I hate our industry for how we copy each other. I hate it. And I'm by nature just a more contrarian person. It's— thank God my wife is the opposite, or I would— that could be a problem. If most of society was me, we'd never cooperate properly. So, but I just have a, you know, somebody— if it's like, well, 15 people say this thing should be blue, I'm gonna see if I can figure out why it should be red and that maybe you've all missed it all along. Um, and in the creative space in orthopedics, that can be really fun because you can find something new, but it also can be a death sentence because it's Class 3, right? Yeah. So, you're always running this dance of, no, no, no, FDA, this is exactly the same as this other thing. It's so much the same that it's super boring. And then, you turn around and tell the customer it's the greatest thing that's ever been invented, no one's ever thought of it. So—

And then, your patent's got to— your patent has to be novel too. So, patent has to be different.

Yeah.

Yup. Yeah.

All right, well, tell us more when you can.

Yeah, yeah, I am in the— I'm in the initial thoughts of potentially trying to find a couple of shoulder specialists as, uh, potential early partners. I have some great contacts going back a long ways, but many of my shoulder contacts are getting to the age where they will retire now. So I need a young— I need a younger batch of shoulder surgeons. So if anybody happens to know someone they think is on the up-and-coming Side of total shoulder replacement. I'd love an introduction.

Look for yeah, you can you can find them yourself.

I will be able to. I might I might even ask some of my old connections like who came through your fellowship program a couple years ago.

Exactly. Raymond, dude, can I put you on the spot? And so I would love for you to tell the story of how. You left Exactech, you were super successful career, and then you found a new thing and you followed it out of the company. I just, I absolutely love that story.

Well, thank you. Actually, can I just before I forget, because I have so many different things on my mind and I'm multitasking last week, I'm trying to remember who it was. Steven Flutie.

Yep.

Yep.

Flutie Davis.

Yep.

A link with a bunch of family office. I used it with the passcode, but I got to nothing. I didn't get a list. All I got was a bunch of names, but no contact information. Did anybody get the actual list of family offices? Because I reached out to him, but I didn't. I don't think I have his email address.

I'm going to give you his email.

Yeah, that would be helpful. I did it on LinkedIn, but he didn't respond. And so I didn't get what I think he was promising, but I got into the website, but I didn't get the list.

Raymond, he had, he had like a passcode. Did you get that?

Yeah, I got the passcode and it got me into the website, but it, when I got to the, I typed in family offices, what happened was It said you gotta pay for the premium in order to get any kind of contact information.

Stephen will, he'll hold your hand. So the best email, I think, is stephen@pitchsync.com.

I put it. Okay.

Yeah.

Put it in the chat. Thank you.

He'll give you a new code if you need it.

Great. That's super helpful. Thank you. So I'm not sure what is so abnormal about Mike's story, um, but I'll share it if you think it has merit.

Well, let me tell you, let me tell you what I remember, and, and then you can fill in the gap. So, Raven, Vice President of R&D at Exactech, I mean, you had— you were, you were over hips, knees, trauma, and you guys even had spine. You were, you were developing a spine business. You were, you were over everything. And what I remember you telling me is, you know, I, I need to find new ideas. When you go to the same meetings, you know, it takes— it's the same idea. Exactly what Kyle said.

Okay.

And you went to a general surgery meeting and they were doing surgery through the belly button. And, and I'm, I'm gonna stop there. That's what I remember.

Yeah. And so what we're talking about is how do you spark innovation? I'll tell you a really good way to spark innovation is you go to a juggling convention. Okay, about 100 years ago, I used to make a living from juggling, which was back in my college days. And if you ever want to spark creativity, there's an International Jugglers Association. So I took a day to do that about a month ago up in Fort Wayne. That was great fun because those people aren't constrained by regulatory and they're constantly creating new juggling routines. Anyway, so get out of the box thinking, which sometimes, and maybe you guys have done this before, you assign engineers, you give them $50 each and say, go down to Home Depot or Lowe's and you got $50 to build a new medical device. And you do it using stuff you buy at Home Depot. That's a creative exercise. But what Tiger's saying is, as I attend a— or my story is, I was in at Texas Back TBI observing an ALIF back in 2010 or 2011. And I was like, oh my goodness, huge incision. They stick their hands in, they push everything aside. All the while, posterior spine is all about MIS. So a few months later, I attend a some type of other medical device conference outside of orthopedics. In fact, that's a pretty— there's an organization called SAGE. I forget what it stands for. Society for something gastrointestinal surgeons or something. It's like the Wild West. Or in spine right now, there's the ASPIN, the Pain Society. It's a bunch of pain and uh, radiologists trying to figure out spine. And so once again, creativity blossoms in those type of settings. So I'm there and I'm looking at a sagittal plane view of an abdomen, and there's a retractor company that's trying to facilitate the da Vinci robot, and they're talking about the appendix or something, uh, gallbladder. And I'm looking at the spine and I'm saying, why don't we do— go to this, get to the anterior spine via the belly button as opposed the way surgeons do it now. So different disciplines of medicine think very differently. So just going to a urology conference or some other outside your field, you'll— and even developers, they're using different materials and different science and nobody talks to each other. So you can learn or they can learn from you. Actually, my story is I'm mostly a joint replacement guy. I spent most of my time doing knees. And then I oversaw hips and shoulders. But there is a completely different culture with joints versus spine and vice versa. And it's— for me, it's been beneficial to work within spine with a knee background because spine engineers are not as meticulous, no offense. Or alternatively, knee engineers are not as willing to be innovative because they're blocked in. And so when you cross boundaries or whatever you want to call it, disciplines is probably the better way to put it. That is an innovation driver. So what happened is Exactech, I was there 26 years on the leadership team. It got acquired by private equity. Private equity brings in their people, leadership team exits, which happened at a perfect time for me because I was kind of tired of the larger company setting. I'm more of a small company person. And I, in hindsight, avoided a lot of headaches at Exactech over the last 7 years and then started Nova Approach Spine, which sprung out of that original invention for scarless spine surgery going through the belly button to get to the anterior spine. And it pivoted to this. Which is our implant. This is a plastic model of it that is in use. And a really cool story last week, I won't name the surgeon. He intended to use a particular type of spinal device for anterior spine. That patient, he could not get it in. He then called for the second company, couldn't get that implant in. Unfortunately, we were number 3. And had it not been for our implant, that patient wouldn't have had the surgery done. And it was a 3-level because the advantage of ours is you can place it multiple different ways. And none of the other implants was— he could safely put in. Had it not been for ours, that patient wouldn't have been treated. So we're delivering success for surgeons and patients and safety. So that's our value proposition. I don't know if that's what you were looking for.

Thanks for that. Thanks for sharing the story. I knew parts of the story. Yeah, that there's great— I mean, look at Mark Riley, you know, he, you know, he basically grabbed an angioplasty balloon and put it in the vertebral body. And, you know, so there's—

Yeah, there's another little— maybe this isn't new for you all, but We also marry 2 different surgeon disciplines. Well, there's the classic marry orthopedic and neurosurgeons in spine because they both deliver implants. We added one more, and that is an access surgeon. And so maybe it's a little bit of what Sheila's trying to do is this multidisciplinary. Now, you got to be careful because there's a pecking order and there's a who's the decision maker. But blending a diverse team, I guess, is probably the best way to put it, has benefits.

I love it.

Hey, Raymond, are you going to Nassau?

Well, I'm right in the middle of debating about that. Probably. I have a hotel room, whether I miss the deadline on the Venture Summit, But I'm not even sure I wanted to do that because it's more of a startup thing. I've been in market for 4 years, so it seems like I get a 10 by 10 booth. Why do you ask?

Well, I'm, I'm going. I, I, I would have suggested that, you know, I not go because there's not a huge reason, but I was told I am, so I'm going. But like I said, I don't have a whole lot set up, um, and that's why I originally wasn't going to go. But it would be nice to meet up with you and—

Yeah, I'd love that.

Talk about what you're doing. My, my whole upbringing was in spine fusion. You know, I'd say 70% of my, my IP is, you know, anterior fusion.

Yeah, I would love to meet with you. So yeah, I— there's about a 90% chance I'm gonna go.

Gotcha. Well, and, and, you know, it'll be something fun to do versus, you know, stuff that I don't want to do there.

Well, we've, we've talked about conferences on BoneChat a bunch, and the rule of thumb seems to be big conferences don't get a booth so you can roam. Small conferences get a booth.

Yeah, well, we would go to have meetings with, you know, you know, some of the strategic companies, but we have nothing new, you know, it'd just be updating, and it's just, it's just not worth it. Um, if, if we had something big to, to, to announce or something like that, that then, then we'd be meeting with them, but we don't. It's— we're just, you know, staying the course right now.

Yeah, do a lot of— I think Ted Berg did a, uh, a session on, you know, all the— it's all in the prep. You have to You have to arrange lots of meetings ahead of time, and it makes the, makes the meeting worthwhile.

We do have, we do have a presentation on our 1-year results, 1 and 2-year results, so that'll be cool. But, you know, that's, that's 5 minutes out of my, yeah, 3 days.

Yep. Yeah, I'm sure you have zero debris and zero issues. Yeah.

Yep.

And our, our results are really, really good.

So that, that's, that's cool. So the biomechanics, you know, definitely are a thing and they're panning out. So that's good. Yeah.

There's definitely, we're about to run outta time here, but there's, I don't know spine world as well as you guys, but I'm hearing from Mark Viscogliosi, there's, this is like the first year where the, the artificial discs actually work and they work really well. And so there's— the surgeons are making a decision, fusion, non-fusion, for the first time ever. And it's interesting. It's very interesting. There's room for both, obviously.

Yep.

And if we could just get enough money to finish out our IDE, we'd be sitting pretty.

Money's hard for everybody. Well, thanks, guys. This has been an hour. Thanks. Open discussion. I love them. Yeah. Next week, I think we've got— I forgot who we've got. We've got a startup presenting next week. So, all right, see you next week.

Alrighty.

Thank you.