BoneChat #94 - Open Discussion - Vendor Credentialing, Digital Marketing, & Botched Acquisition

Vendor credentialing.

Oh boy, for—

that's the hospitals, uh, you're not talking about RepTrax, you're talking about other stuff?

Yeah, RepTrax.

Oh, RepTrax.

Yeah, and, um, and where those companies are going. I'm thinking about it more as a business than I am a burden.

Oh, I like this, Mark. You're thinking about a new system that's easier to use and has more transparency, maybe?

Well, I'm just kind of thinking about why it started. I just, you know, kind of like Joe was talking about value analysis and you know, why it's there, how it's used, uh, the more— if you understand it, you can manage it. It would be a good word to put it instead of just hating it or fighting it or resenting it. You don't get anywhere by, you know, reacting emotionally to something like this. Um, and I was just curious. I mean, I just think it's an— to me, it's a fascinating subject because, you know, I also I spend most of my time with VenOps, and VenOps does OIG exclusion screening compliance. It also handles HIPAA, and our focus has been on medical practices, but we're switching to hospitals.

Hmm.

So I'm finding myself strategically talking to companies that are also dealing with non-clinical people in hospitals, the business people, the compliance people, the legal team, general counsel. And I'm just trying to figure out, um, you know, where I think they might be going, where the synergies might be with what I'm doing, you know, whether I want to partner with them or replace them or kill them.

Well, it's Anyway, I think, I think it retracts like the beta versus VHS argument where it's probably not the best system, but it's, it's ubiquitous, it's everywhere, and it's be really hard to displace it. Uh, yeah, it's— when did it—

you know, I hear you say that. Yeah, but you know, me and, uh, Kishore and Danny introduced one of the first EMRs at the Academy in 2001. Wow. And it spoke orthopedics real well. And it was very doctor-friendly, doctor-centric. And, you know, a few years later, you know, we're looking around the industry for EMRs and we're thinking, okay, there's 3 or 4 out there. I guess they got first mover status. They're gonna own it. They're gonna be there forever. 10 years later, nobody that bought an EMR in the early 2000s had the same one. And you'd think that that would have been something extremely difficult to change or replace. But, you know, every— when you get a faster horse, people switch. So, hey, I just was thinking about—

that's really— the switching costs are really cheap.

And that's Well, in digital, it's— they're super cheap. There's no inventory. Nobody has to go clean off a shelf, learn a new technique.

Yeah.

And most of the time, the standards come from, like, regulatory bodies, you know. And— but there's no global hospital group that can dictate standards, really. That's another—

even if the— you know, even there's fit— States have their own rules, but there's 50 different, you know, 50 different sets of state requirements. I don't see— it's hard to see them going, uh, it's hard for me to see them going anywhere. I mean, they could change, um, I mean, they have a risk of like getting taken out by state governments if you ask me, but, um, but I don't necessarily think that's likely.

What's the— what's— make the case, Mark, for what's not working with RepTrax. Obviously the device companies hate it, but what's not working for the hospital providers?

If I am a— if I'm a clinician, What does it do for me?

It—

nothing. Exactly, exactly. Okay, that's nothing. This doesn't, this doesn't do anything. But what could it do for me? What if, uh, the State Medical Society took it over and, you know, the cost that's now going to the hospital, or now that the cost is now going to this whatever you call, RepTrax or vendor-made or whatever they might be, goes into the state medical society? You know, or what if those costs are shared? Or, you know, what if part of the program is tracking clinical trials or an alert system for a change in a surgical schedule or an alert system for You know, anything that would benefit the clinician. And that's my question. I mean, reps hate it. There's no cost to the hospital. We all watched it get born through some pretty clever salesmanship. In the beginning, there were kickbacks to the hospital. That's all kind of gone away because, you know, of the Affordable Care Act and anti-kickback and so forth and so on. So they don't, you know, the only thing they get at, the main thing that they get out of it is that they can finally kind of like value analysis, control reps' ingress and egress.

Yeah, it's sort of a function that they wanted to have that they can conveniently sort of just outsource the function. To a third party. They can sleep easy, sort of knowing that the function is taken care of and they don't have to do anything.

Exactly. Back when there was like a public hospital, you know, Hillburton Hospital, you know, they would tell reps, you can't sell, you can't go sell that to this doctor. And rep would say, go screw yourself. Yeah, it's public hospital. I can walk anywhere I want, blah, blah, blah. Well, now because of this system, They can actually tell you, you can't, you can't come in my hospital without doing all this and paying $400 a year. Kill me. And if you, uh, screw up, they can ban you easily by taking you off the system. They finally, finally almost found a way to control it. And I just, you know, in the beginning they, they disguised it under safety and sexual harassment and and all this other stuff.

It's like bio burdens.

Yes. Yes.

Yeah.

Infection control, you know, sterile. I mean, it was all bullshit.

Yeah. So I think what happened was the, I mean, I just looked it up. So Reptrex was started in 2006 by Peter Sheehan. Yeah. But it started when surgeons started losing control. They started losing their voice. They started becoming more and more employees. And we're not gonna let you have your friend in the operating room if, you know, they're not really helping things and they're upselling the hospital these new systems that we don't even want. We don't want that guy in the operating room. I think that's probably, that's probably a coincidence that it started when physicians started losing control on product choice.

I don't think it's a coincidence. I think it's like, I think it's like correlation. Yeah, I think it's correlated that the hospitals— it's impossible to know this for sure, but the hospitals probably never liked the practice. They all, you know, they always, if they could have gotten their way in, in 1998, they would've, you know, done something about the reps, but they felt the need to, you know, this is general stereotypes, but the surgeons or the clinicians liked the reps and the hospitals were vested in keeping the clinicians satisfied or happy. The hospital viewed the clinicians as, you know, their customers basically. They, you know, the clinic, When the clinician has the ability to sort of get upset and say, I'm taking my patients to the facility across the street, the hospital has a great interest in keeping the clinicians happy. When the hospital turns those clinicians into employees, maybe they're special employees, maybe they sort of are treated a little bit differently or a little bit better than your average, you know, whomever around there, but they, they, then the hospital, it's, you know, the loss of the clinician's voice and importance in this is, it's completely sort of inversely proportional to the rise of the hospital's influence. And once they don't have to worry too much about the clinicians being their customers and they're more their employees, they can start doing sort of whatever they want.

Yeah.

Can control the, comings and goings of device people. That makes sense.

Do you think this coincided at all with the prevalence of hospital contracts, like big-ticket contracts, and it— RepTrax became an excuse to keep out new innovative companies when you were already going to be on contract with ZB and would have been just Zimmer at the time. It just became an excuse or a barrier of entry?

I, I don't think it's coordinated or conspiratorial, but I don't think it's coincidence. I think it sort of fed into each other, now that you mentioned that. Um, I, the, the, the— I did research in 1999 on the numbers of orthopedic practices that were independent versus that were hospital-owned or government-owned. 24% of all orthopedic practices in 1999 were actually solo practices. Not private, but solo.

Okay?

The vast majority were private. And you see how fast forward, I think it's now like 70% of them are either hospital-owned or private equity owned. The actual private practice is now very much a minority. And I'm not sure when I started saying this at dinner to doctors, but I would, I remember as long, it might've been even the, the '80s or '90s, the hospital's not your friend. Don't ever forget that. 'Cause they're really not. I mean, they're, they have a symbiotic relationship, but they tried to figure out ways to control what doctors were using for a long, long time. And now, with— since they're an employee, most of them, they can do that through contracts, through vendor contracts. Now they control their reps too, which they never liked reps anyway. I mean, I kind of have a little bit of a unique, uh, experience in that the summer I graduated high school, I became a scrub tech because my dad was chairman And I, there was not one, the next two summers in which I scrubbed on trauma and everything else, there was never a rep. I never saw one rep in the operating room. The only rep I saw was the Codman rep selling instruments in the break room. You fast forward to when I get outta the Army and my first arthroscopy, the doc asked me to scrub. And that, you know, was shocking to the crew. But it wasn't that uncommon, you know, in the early '80s. Now you can't even open your operating room on Monday morning without reps 'cause they're the only ones that know where the instruments and the inventory is. And they, they work quote for free, but not really.

Anyway.

Well, also if you go that far back in the early '80s, I went to my first case in like '85 and I was surprised to learn that hospitals just bought all the instruments and they had 'em, had 'em right there and they bought all Here's all the implants.

Here's—

we got 27 sizes of knee.

You like literally sold someone a total hip system. Like you sold them everything. Like here's the implants, here's the instruments, here's everything.

You didn't need a rep because everything is right there and the nurses can read the labels. And it only became a pro— the reps became more needed when everything went to consignment.

Yeah. Well, because if it's on consignment, you don't care if the inventory gets messed up.

Right.

If you're at the hospital, I was on a project with J&J a couple of years ago and we were working on like logistics stuff. It was a special project, and these VPs of logistics and procurement actually would joke, we've got over $1 billion of inventory in the marketplace and we have no idea where it is. That's not funny. That's not funny, guys.

It's not funny. Here, Raymond's got his hand up and he's driving, or maybe he's a passenger.

Yes, passenger, and hopefully the connection's good. Can you hear me okay?

Perfect.

Okay, good. So interesting conversation, and I'm wondering if in fact this last comment about scrubbing, if this thought might be helpful in this discussion, and I'm assuming it's still true, but if you go over to Europe, especially Germany, it's 180 degrees opposite. The reps there are actually expected to scrub. That's part of the task. And so instead of being put in paper scrubs, you know, with the, you know, terrible RepTrax, whatever requirements, there is part of the value that a rep provides is literally scrubbing and assisting the doctor.

And it's mainly at Oh, went through a tunnel.

Uh, we're losing now, Raymond. We're losing you.

But Raymond's right.

Did you hear the—

I still work with European companies, and when I go over there the regional rep or whomever is very often scrubbing, helping the back table, helping the mayo, helping the doctor. This goes next, whatever. It's a different relationship.

Yeah.

Yeah.

I don't know if it'll help.

Go ahead.

Who makes the product choice decision in Europe?

I'm pretty sure the surgeon, but again, it's been a while since I've been over there.

There's an extensive tender process though. Okay. Most often what I've seen is it's pretty equivalent to like multi-vendor, what we would think of as like multi-vendor contracts that are administered not by, but not by a health system, administered by depends on the country, but most often sort of a provincial level type of, um, you know, or even maybe like a subprovincial level type of setup.

So it's like Kaiser Permanente putting it out for bids and everybody presents their stuff?

I mean, there's exceptions all over the place, but like, that's what I've seen the most. It'd be— but if like Kaiser Permanente was not Kaiser Permanente, it was like, like the state of Alabama or something like that.

Interesting. So what if in your new business model you hire a bunch of scrub techs who essentially represent the company, but what you're providing the hospital is free scrub tech services. And so you have a scrub tech, but he's also in there to try to sell.

Has anybody ever tried that?

Just because it's never been done before doesn't mean you shouldn't do it.

It's true.

I don't know how that would work.

Well, I mean, it's, um, there are, there are scrub techs that do first assist.

Mhm.

I know the rules and regulations are You know, they are what they are. I'm not sure what, what they are currently, but that's an interesting idea. Anyway, I'm just curious because, um, my Venoff's company, you know, we, we do compliance for, um, we have over 1,000, uh, active medical practices that do us, use us, and we We just signed an agreement with a company called ORTrax to do their OIG exclusion screening. And they are essentially a vendor, RepTrax company. And, you know, everybody in my organization is kind of champing at the bit to take that service to some of their surgical center, surgery center clients. Because the core software is one that has alert systems whenever there's a change in the surgical schedule. It alerts the surgeon, the rep, and the OR all simultaneously. And it's an active system so that you have to answer. If you don't answer, it bings you again. And any of us that's ever been in the surgical world, and I think all of us have, have known what it's like to get that phone call at 7:28. Hey, who's covering my case? And you go, oh shit.

What do you mean?

So my question about that, Mark, about what's it called? O-OR-TRACS.

Yeah.

O-OR-TRACS. Is what feeds the system? I mean, every hospital's got different scheduling systems. So how, how in the world do you feed the O-OR-TRACS system an update notification? Like, it's got to be an API or something, and that's—

You know, they have to coordinate with Epic or Cerner or whoever is in the hospital EHR system, which very often that's where the surgery schedule's kept. But that's a, you know, that's a simple HL7 or FHIR And they, they, that's not that hard to do.

Okay.

And I think there's room, like, to what you're describing, Mark, to, like, displace existing credentialing systems by offering sort of more services in addition. But I think that, like, the core services are staying. Like, I don't think they're, like, I don't think it's hard for me to envision 5 years or 10 years from now where it's like, remember that crazy time when we used to do vendor credentialing and now we just don't? Like, I don't see that world.

I agree with you. I agree with you.

Happening. But there's room to like bolt on, like in a way that actually could be at least like semi-interesting to the, to the actual paying customer. I mean, the paying customer is over a barrel with, with these systems, like, because you just have to, like, you just have to pay. I mean, um, they keep raising the prices, people keep complaining, and every— nothing changes. And it's probably going to keep going like that until they get—

I agree—

some, some price in the future that, that you know, is not palatable. But there's ways to like have a better version of these things that is like better integrated with the OR, has, you know, different ways for, who knows, messaging, or I'm sure there are definitely, I'm sure, features that like you could take communication platforms that already exist and add on the vendor credentialing part and you have a more comprehensive system for sure.

I think one thing that would be needed would be like a Yelp kind of thing, a reputation score. I think it'd be really cool for reps. And I don't know if this would be RepTrax Plus or a brand new system, but, you know, somebody goes in the operating room, they're in the system and they get a score. You know, this guy was useless. We give him a 1 out of 10, or this guy was awesome. He found helped the scrub tech find an instrument, we gave them an 8 out of 10. And I mean, it's just like Uber drivers. Everything now has got a reputation score. You— we make, we make service decisions every day based on reputation scores, whether we like it or not. You go to Amazon and you look at the consumer reviews. I think that would be helpful. I don't know how it would work, but I don't know who would provide the feedback, and it would be voluntary, obviously. What do you guys think about that?

It's pretty intriguing, actually.

It would weed out the bad. I mean, everybody would be on their best behavior. They want to get a 5 out of 5 score, like your Uber driver.

I'm just laughing because I'm thinking of this rep that used to work for me that one time after a case, the surgeon called me and he said interior cut of a total knee. And Jim's over there in the corner with his back to the case and he says, so Jim, get ready to make the cut. How's it look? And he's swinging. And Jim says, looks good, Doc.

He's not even looking.

Ah, I know it sounds terrible. And fortunately the guy had a good sense of humor because, and he didn't really need a rep to tell him the cut was good.

Yeah, it's just ego thing.

But I don't think he would've gotten a good score, Tiger.

No, he wouldn't have. And that it would've weeded. And the companies, the, the distributors and the medical device companies wanna know who's good and not good in the OR. I mean, the main thing is sales, right? But I don't know, that seems like a reputation score would be a step up.

Well, if you're gonna do that, you might as well add a tip function, 15%, 18%, 20%, 25%, automatically. Goes to the purchasing agent. Yeah.

And they're not HCPs, so it doesn't have to get reported.

Oh boy, interesting.

I tell you what. Or the other way around, the company should get the tip, the rep. Oh gosh. Come on.

So another conversation that's, that's been batting around, and I know Will enjoy this, is I've had multiple conversations in the last month of people that have just, when it comes to social media marketing, uh, email marketing, text marketing, uh, trying to build customer bases, have just thrown in the towel, kind of figuratively speaking. And basically accepted the fact that if one human being is not talking to another, nothing's ever going to happen. And I guess you could say that about recruiting too.

Yeah, the— this— what I've— so back when COVID happened, I did some digital marketing consulting for a few small companies in ortho, and they wanted— the, the problem they have is they want an instant ROI. You know, they want to say, okay, we're going to spend this much on Google Ads or Facebook Ads or whatever, and I'm going to get, you know, 10 new customers in, in like a month. And they just— and, you know, it doesn't work like that. You know, it's—

oh, it's— I think it's expectations sometimes of like, like most of the time these digital— this is at least my opinion— like these digital marketing services, they do really good at potentially like shortening the sales cycle, or they can do really good at like introducing things and staying top of mind and like acclimating customers to ideas. But they're not like, if you expect them to sort of close for you or take you all the way through from like never heard of this product before to like a routine user of said product, that's not going to happen. But what they can do It's not like they can eliminate reps, but they should in theory, like make sales forces more efficient and like maybe thin them out over time. It's like you can, if you don't have to constantly, like if it takes, this is like a fake example, but if like, if it takes 7 interactions or 7 exposures to a certain product before there's a buying decision, like you can employ an appropriate number of people physically to like do interactions 1 through 6. Physically and then close on interaction 7. I know it's not this simple, or you can like sort of use these digital tools to expose people to product, the, to the product for times number 1 through 6, and then have a person come in sort of at, at exposure number 7 and close. And in theory, you should need less people if they're sort of spending more of their time closing. But I think there's an expectation of like, great, we'll do all these digital marketing things and then like we don't need reps, or we can get rid of our sales force, or, or something like that. It just doesn't— like, they're— it's like background for— it's like, yeah, it's like, yeah, this is like very normal in regular things. Think about like, I don't know, how we buy cars or something like that. Like, you see stuff on commercials 20 times, you see stuff driving around all the time. It's not like you, you'd never hear of a car the first time because a car dealer calls your house and then calls your house 6 more times. Like, and then on the 7th time you're like, now I'll buy. It never— it doesn't work like that with most things. So It's, it's, I think it's an expectations mismatch.

Yeah, I think you're right. It's, you know, you gotta see, the surgeon's gotta see the product at a medical show. He's gotta see that another surgeon's interested in using it and having good results. You know, he's gotta see maybe a white paper and, and then eventually a knowledgeable rep. He asks for or gets sent a knowledgeable rep and, but it's, you're right. You gotta see it in multiple places. Surgeons like to see somebody else using something before— nobody wants to be first. Yeah, it's kind of what I found.

Mm-hmm.

Why do, why do all of us suck at lead generation? I mean, how many, how many companies really have a, a vigorous productive lead generation service that really gives leads to dealers. I mean, when I've tried a couple of different times on different startups to build what I used to call hunter-killer teams— the hunter would be the lead generation rep, you know, there at the office, at the home office, calling doctors. The killer would be the guy that takes the lead it makes the phone call, tries to set up an appointment. And, uh, I could never really get it off. I could never get buy-in on that. I thought it would work because it, you know, works in battle.

Anyway, I just—

yeah, these are, these are age-old questions that—

yeah, it's still— I think it's still a reputation or a trust kind of environment., you know, with reps and surgeons. Yeah. You know, and it's also surgery is different. Orthopedic surgery is different than other surgery because you have to touch it, feel it. You have to— there's a tactile feedback training. Everything goes to cadaver lab training before the first use, usually. I don't know. It's— yeah, Raymond's got a question or comment.

Yes, if I could go back to the social media aspect of the conversation, and I'll put myself out there, and I don't know how many people are on this call, but I would welcome feedback if you're willing, any of y'all, to give me feedback on how Nova Perch Spine, my company, is using social media. Let me think, about a year and a half ago, we enlisted support from a former colleague of mine when I used to work at Exactech. She's a marketing communications person who I personally like, but I need outside opinions on the nature of the kind of content that we're creating. And I mean, I got thick skin. If you don't like it, let me know. Or if you think it could be, you know, altered, or if you think, hey, I'm making unsubstantiated claims or anything like that, we try not to, but I would welcome it. If anybody else wants me to give them feedback on their stuff, to me that would be a benefit of this group to, I mean, privately, you know, communicate to each other feedback if that's of use to anybody, but I would welcome it.

And what is your website? Yeah, it's in the chat, Mark. I put it in the chat. Nova Approach.

Fine.

Yeah. So really, it's the LinkedIn, not so much our website. I mean, you could comment on our website too, but I'm really referring to the posts that we make on LinkedIn. That to me is more of our awareness campaign to just, you know, reps and distributors. That's mainly our audience, secondarily surgeons, but mainly it's distributors and reps is our intended audience.

Okay, so I can give you feedback right now.

Please.

I'm looking at, so the, the, I, you know, I, I do a lot of social media stuff for myself, so, and I kind of see what works and doesn't work. The, I think the number one problem that medical device companies have is they don't post enough. So you should be posting probably 5 times a day on LinkedIn. That's the number one thing. And it's not because, and nobody sees it. So as you guys know, I write articles every day for almost 20 years. And I have people that call me up and they say, hey Tiger, I just read your article today. And I said, which one was that? And they tell me, I said, well, I, and I'm thinking in back of my head, I wrote that 5 years ago and I've reposted it probably 200 times and you just saw it. And that tells me nobody sees anything. And so the only, the only answer is you just have to pound. You gotta post and repost and change it, make it longer, make it shorter, add an image. You just got to post like crazy. That's the number one thing. It's, it's quantity works, quality does not work. This, the second thing is on, on LinkedIn, videos do really well. Videos get per LinkedIn, the LinkedIn algorithm likes videos a lot. So, it gets pushed to more people.

Really?

Most people don't know this, but if you post on LinkedIn, if you go right now and post on LinkedIn, it sends it out to about 10% of your number one contacts and then it just stops. So 90% of your number one contacts never see it. And then it, if the algorithm sees if people are liking it and commenting and sharing, then it goes to like 50% of your number one contacts. And then if, if you still have some traction, eventually goes to 100% of your— but LinkedIn doesn't even show it to, to everybody. When you post, you think it's going out to everybody. It's not really.

Yeah.

It's because the algorithms are so smart. They don't want— the LinkedIn of the world want the best stuff at the top of the feed. And so they use the algorithms to figure out what the best stuff is. So that, those are the first two things. Quantity, quantity, quantity, and, and use video as much as you can.

So if you've got like 11 or 12,000 followers like I do and I post something, how many of them, I mean, not that many are gonna even see it, right?

Well, not initially.

Not initially. 1,000 are gonna see it if they just happen to be on LinkedIn at that moment.

That moment.

Okay, but it's like a river going by, and so 5 minutes later it's way downstream. That— your posting's gone.

They send it out to like a percentage of your contacts and then like wait an hour sort of, and like see, like, did people engage with that? And by engage, it can mean a million different things. The like— it could be the thumbs up, like button, it could be commenting. And then sort of like based on what happens in that first hour, then they choose like, okay, well, this, this seems to be getting good traction, let's sort of spread it out to a wider audience or like a narrower audience or a wider audience, like based on like how it, like how it goes. And if it keeps getting good engagement, they keep widening the reach further and further and further.

Exactly. Well, well said. So that's the reason the algorithm is against— it's designed to be against us all unless you have something compelling. So that's why you have to just The third thing that companies don't do is trial and error. So, I would, if you're going to do a post, write the post 5 different ways and send it out 5 different ways. Send it out as a text, send it out as an image, send it out as a video, send it out short form, long form. And then you get to watch, you know, within 24 hours, well, wow, that one worked way better than the other 4. So I'm going to do more of that. It's instant metrics.

So for our business, is it— is LinkedIn is by far the best, correct?

I think LinkedIn for— yeah, if you're— it depends on who you're—

yeah, it depends on who you're trying to reach.

If you want hospital surgeons and device companies, I think LinkedIn's the best.

Yeah, B2B. Yeah, not B2C, right?

But YouTube, I'm a big fan of YouTube. I mean, it's the thing about YouTube. If surgeon watches your thing, then it's going to recommend it again to the surgeon. And LinkedIn doesn't do that. See, LinkedIn is a river. Once the river goes down, it's gone forever, right? Whereas YouTube, it's going to, it's going to say, hey, Dr. Maloney, You liked that last Nova— Nova Approach video that you watched last week. Nova Approach just— they just added a new surgical technique. You may be interested in this. It's like Netflix. So that's powerful.

How do you use YouTube?

Well, I just throw everything on YouTube. I mean, and I just see what sticks. Yeah, all the bone chat discussions go on YouTube and I— I cut it into small snippets sometimes, you know, and it's, I don't know, it's, you really, the YouTube, you really want to get subscribers. It's hard to get subscribers on YouTube when you're in the medical device world, but I started with zero. I've got about 300 subscribers now, and every time a new posting goes up, those subscribers get a notification.

Oh, okay. Huh.

YouTube, not, not Vimeo.

Vimeo is a closed— YouTube is, it's available to the whole world. There's billions of users. It's part of Google. It's connected to the Google search engine too, which makes it super powerful.

YouTube itself is like the second or third largest search engine in the world.

And it's close, it's becoming, it's close to Netflix now on the number of hours people watch. Really? Yeah.

It's, if any of you have elementary school age kids, you'll know how much time they try to spend on YouTube.

The other thing about YouTube that's unique is you can find your tribe. So whatever subspecialty you're into, and I always make a joke that if you're into midget wrestling, and you start watching, you watch midget wrestling on YouTube, it's going to recommend more midget wrestling and you're going to be, you're going to be hanging out with 1,000 people in the world that just love midget wrestling. And you can find, you find your tribe really fast where LinkedIn is. You can't do that. It's really hard. Too much noise. Yeah, the other thing, Raymond, if you're gonna go YouTube, you don't— you have to be very specific. The, the smaller the niche, the better chance you have. So if you, if you just say we're a spine device company, that's not gonna work. If you're gonna— I don't know what your, your brand pitch is. I remember you start off with OpenOrifice. Surgery. If you start off with something really specific like that, open orifice surgery, then you— wow, you're going to find people that are crazy. They're searching for open orifice surgery and they're going to find you. But if you're a spine device company and they're searching for open orifice surgery, you'll— they'll never find you. So you have to be specific. You have to be very nichey in YouTube.

That's a good tip.

Had to be niche rich.

Niche rich. There's more specific. That's why midget wrestling works, but you know, spine, spinal cage doesn't work.

I'm very careful about what, what I watch on YouTube cuz I don't wanna open up YouTube and all of a sudden all I see are midget wrestlers and everybody knows that.

Yeah.

Right.

Yeah. It'll follow you. It'll take you a year to shed that off of your, like, your, your algorithm.

Oh my God. I watched this Cracker Barrel commercial with Sydney Sweeney, and for the next week, my YouTube was like, oh, that's not me. I gotta get outta this.

Yeah.

True. Algorithms are so good. But you can, we can use as medical device people, we can use the algorithms to our advantage. By picking a niche, you know, by, uh, being really clear messaging, by just doing it over and over and over again. Um, yeah, I wrote— Raymond, I'll send you the article. I wrote an article on the top 10 things that an ortho spine startup should do in digital marketing. I'll send, I'll send it to you.

Yeah, please copy me too. Yeah, okay, we'll do that. I sent you— I emailed you before the call, uh, the— all the summary of bullet points from Joe Colonna's, uh, talk as well as the complete transcript.

How good was that? I mean, that was— that was one of the best speakers we've ever had. I mean, wow, just to look behind the curtain and see how giant hospital business thinks. That was, that was enlightening to me.

It was. I thought it was frightening, but it was enlightening too.

Was it lightning?

I met with his counterpart Tuesday morning for another hospital system, and, um, you know, without telling him that Joe had come on and kind of let us look behind the curtain. I, I've said a couple of things, and he, uh, very much echoed much of what Joe said. And he did say this year that their hospital system, uh, is doing— is having to do more with less. He said 2020 2024 was very good. 2025 is not nearly as, you know, reimbursement-wise as good.

Yeah, the message was loud and clear. If you're a device company, you have to help the hospital save money or make more money or reduce labor or something, or you're just, or they're not even gonna look at your thing.

Well, since the advent of the vendor credentialing program, I can't tell you how many dealers and reps I've heard say that my days of helping the hospital with a discount are over. They're so pissed off having to pay that $400 or $500 a year that they don't feel like they want to help the hospital. That they had— like Joe was talking about, you got to get over that. You got to figure out if you want your product in that hospital, you gotta figure out a way to, you know, be on the same team.

Yeah. It's, you gotta, it's not a, if you have, if you have an adversarial relationship, the hospital's just gonna stiff arm you. You have to help them solve their problems.

That's right. You're not gonna win that battle.

Yeah.

Boy, that was really good. Joe was really good. You know, Copeland called me after and he said, I was, I was kind of in the— I was ready to argue with him. He said, I was all set up, ready to argue, but Joe was— had everything right. He said he was like, it was perfect, you know.

Um, you know, he, he never went to college.

Yes, good for him.

Uh, he went in, he joined the— he enlisted in the Navy out of high school and He has climbed to the top of where he is. I mean, just experiential learning and credentialing and doing, you know, doing the right thing.

There's a lot of people that never went to college that are, you know, the most famous story from Memphis is Ronnie Pickard, who basically He basically made Danek what it was. He was the first real CEO of Danek, and he started off, he never went past the 8th grade. He was mowing the lawn at Richards Medical, and he talked himself into getting a job in the warehouse with no high school degree. And then within about 10 years, he was director of operations, and then he became the president of Smith and nephew, and then he quit and became the CEO of Danek, and the rest is history. Ronnie Pickard was pretty, pretty amazing guy, and he just read books. He just read business books. Like, when, when, um, I may be boring you guys, but what he did— he, he was all about speed. So when he was at Danek, he had a rule This is back in landlines before there were cell phones. Said, if the phone rings, you have to answer it within one ring or you're fired. That was one of his rules. Damn. I mean, man, people ran to the phone, you know. Another thing he did was, this is back in the late '80s, early '90s. A surgeon would come into the Danek, meet with the engineers. And they had a crappy 3D-printed plastic, like, thing, like a microwave. And they— while the surgeon was taking a tour, the engineers would print the surgeon's idea in a 3D plastic. And Ronnie would meet him at the front door before they went to the airport. He would hand him the prototype and say, "Doctor, is this what you were telling us about this morning?" You know, let us know when you want this in titanium, we can make it for you in titanium. I mean, that, that was 35 years ago.

Wow.

I mean, I mean, that surgeon was thinking, they walked away, they were in the airplane holding this thing. They're going, wow, if I'm gonna develop any products, I need to work with Danek. These guys are fast.

So the question I asked the guy from the other hospital system was the same one I asked Joe when I first sat down with him. I said, um, what formative experience in your early life made you ambitious and made you hard, hardened you, or, you know, made you ambitious? So he gave me an answer I never expected. Uh, Joe had a good answer too. So first thing they always— when you ask that question, they always say, well, what— tell me yours. And I say, well, I dropped out of college when I was 19 to join the Army because I didn't want to miss the war. My first week at Fort Knox, I was on KP in the winter outside scrubbing pots and pans, and I swore I would never be on the bottom of any organization again. So I said, that was my experience. So this guy told me, he said, I grew up in Flint, Michigan. He said, I graduated high school in 1981. Life was, life was not good in Flint. I had, I had an interview and I was the top candidate for a 3-year electrical apprenticeship with an automaker. I didn't get the job. Because they said, the HR said they had to hire either a female or a minority, and I couldn't do it. He said that was not the formative experience. He said, I just took that with a grain of salt. It was wrong time, wrong place. I didn't, didn't, it didn't ruin me. I went home and told my dad, who was, who suffered from OCD. He kicked me out of the house that day.

Wow.

Because of that. I lived in my car for a year and a half. This guy's a senior VP of a 25-hospital chain. He said, I lived in my car going to community college for a year and a half. I didn't even have enough money to buy gas for the heater in the Michigan winter. He said, that experience gave me ambition. I said, damn, you know, I love that question. You never know what you're going to hear. That's a good story.

It's a really good story.

Wow.

At another time, I'd love to ask you guys that.

We'll go around the room next time.

Did you guys—

Tiger?

Yeah.

Can you explain? I could not understand. I read the article that you wrote today about this. This deal just like got past me. I didn't see this happening. Yeah, can you explain in like what is going on?

Yeah, the way I understand it, so Intragram is a, uh, what are they, Finnish or Swedish?

Yeah, it's a Swedish company that makes like a prosthesis, like a, like a, um, an internal prosthetic, like an implant prosthetic hybrid. Yeah, like you, you, you anchor it into the bone of the, the remaining portion of the limb and then there's like an attachment piece. Yeah, yeah.

Yeah, let me— I got to show you this, uh, if I can find it here.

But they— so they were going to get bought, right?

So, so Osteocentric, which is, uh, made a tender offer and basically paying them 10 times sales. Uh, yeah, I'm going to show you this chart here. This is the anatomy of a botched acquisition.

Look at that.

Yeah, totally.

Yeah.

So they offered him $100 million and this company's only doing $10 or $20 million a year and they're losing money, they're bleeding. And the mistake they made was, I don't know if it was osteocentric or the IntraGrimm side said you have to have a 90% shareholder vote in order to get And they only got 65%.

But then there's a dispute, right?

Of like, like there is a dispute, which I don't understand exactly. The way I— this thing's dead. The way I understand it, it's completely dead. And I don't know if it's Swedish shenanigans or I don't know what happened, but it's, it's gone. I mean, look at this. That's the craziest stock chart you'll ever see.

It sounded like when I read the article and like I tried to do my own research, like they talked about how like the exact number of shares that the founder owns is like in dispute because like some of them are owned by him as like an individual. Some of them are like wrapped up in some other business. And then like that one of those businesses like merged into another business and like they never kept the paper. Clean, uh, in terms of like, like the cap table got kind of a little, like a little messy over time. And like they didn't actually even know, which is— I mean, these are public— this is a publicly traded company. The cap table should be like quite, you know, it can be long but it should be clean. And, um, you know, it just wasn't like organized properly. And, and that, you know, um, but like it also seems like they might try to go to— I don't think this will get anywhere But they might try to go to like the Swedish financial authorities and like say like, hey, this is like, you know, like this is— we were actually correct here. We were over the 90% threshold, like, and they're backing out now. And they, they sort of can't, I guess.

Yeah, I don't know. It's, it's over my pay grade. But then there may be some international M&A, you know, things that the government has rules for, I have no idea. I, I think it's a good thing for Antegrim actually, because it shows their, their business is worth $100 million legitimately.

Yeah, it does. It puts an anchor price out there.

The anchor price.

And it also, you know, I'm not a big fan of Osteocentric. They're, I don't know if you, how much you know about the company. They're at the, they have a new thread. The technology's awesome. They have a thread that bites into bone like crazy and easy to take out. It's a better thread. It can be used in spine, sports, everywhere. The problem has been focus. They haven't really, they tried to go after the trauma market first and then they got it. They tried to boil the ocean.

Yeah, yeah, yeah.

And make their own implants. And now they finally got smart and they're just licensing it to everybody. But I, I didn't see how buying, you know, that, that other company was gonna do anything for him. It's a really small market, right? And it's, and there's a lot of, there's a lot of military and there's connections. Yeah.

Not just a small market. Yeah. It's a different market.

It's a different market. And like, and I don't, Kyle can speak better than this than I can. I don't think fixation of those like external prosthesis, I don't think that's the issue. Infection is the issue with those. Like when you go, when you have something going through the skin, in, infection is going to be the issue. I don't think, like, I don't think that's basically like a one rod that goes up and down.

Yeah, I agree.

I don't think loosening is the issue with those, that like some better, you know, some better thread is like gonna meaningfully improve those. I, my understanding always was that, that like they— because I used to be in a business involved with, with, in this space. And they always had a tough time explaining to regulators that like, yes, like, this is, this is so much better than the traditional stump prosthesis that basically you should let some infections happen. That like, basically it's still preferable to have a certain percentage of these get infected because it's so superior. And not all infections are exactly the same. And like, but infection, because there's, there's literally like a rod, one end of it is in the bone, the other end of it is outside exposed through the skin, that infection is the issue, not fixation.

Yeah. And it solves the socket problem. That's the socket problem. If you just put a plastic thing around skin, that's, yeah, those people have, they have sores for, yeah. Yeah. It's, it's a terrible thing. Solve the socket pro— I agree.

It's, that was my first thought was I didn't understand the fit. I'm like, why, what do these guys want with, like, what are they spending $100 million on, on a, on this? You know, very cool device, but like, I didn't, I didn't, I didn't at least initially see the, like, the fit.

I didn't, I didn't see the fit, but it doesn't surprise me because OsseoCentrics kind of, they're scatterbrained a little bit. I mean, they're trying, they're going for dental and spine and SI fusion. They're going, they're trying to license their thread to everybody in the world. Yeah, I don't get it. They're not an implant company, really. So we have the same, we have the same thoughts, Patrick. That was kind of interesting. And you guys, good job.

Good to see you. Yeah, me too.

Yeah.

All right, it's been an hour. Thanks, guys. We'll do next week. I think it's open too. And let's throw out a speaker if you have another speaker. Joe Colonna was awesome. So wow, do that again.

Thanks, man.

Okay, thanks.

See you guys.