Dr. Tea Nguyen, DPM (00:53.922)

I want to welcome Dr. Ronan Elefant to the podcast today, who is going to talk about surgical access in direct care. So welcome to the podcast.

Dr. Ronen Elefant, MD (01:03.426)

Thank you. Thank you for having me.

Dr. Tea Nguyen, DPM (01:05.197)

I'm so glad that you reached out because I am so interested in what you have to share and what you do. So why don't you take us back in time to where you decided direct care was the path for you and what you have created.

Dr. Ronen Elefant, MD (01:18.638)

Sure, so I will take you back some time. I didn't know at the time that I could do something about it. I wanted to, but didn't really materialize until many years later. the first, I guess, exposure I had to it was back in residency. I think I was a third year resident or sometime between third and fifth year in general surgery. And it was right about the time that Obamacare came out. And

I just knew that it was not going to work out. I don't remember exactly how I stumbled upon an article about healthcare not being a right. you know, if I, if I can find it, if I can remember, I think it was, written by Leonard, forget his last name, but he was a contemporary or a disciple of Anne Rand and he wrote an article.

That was very short. was like two pages about why healthcare is not a right. And if healthcare was a right, then you would be able to sort of force the person providing the healthcare to do whatever you want. And that does not jive with a free market. And again, I knew that things weren't right with Obamacare, but I couldn't express it. So I started reading a lot about healthcare economics, economics in general and healthcare economics in particular. I think it was.

Again, in my third year of residency, I walked around with Anne Rans, Atlas shrugged all the time. And whenever I had a few minutes, I read, if people know that book, it's a very lengthy book and mine actually has tabs in it that I put down and things that I wanted to remember. And I read a book called Basic Economics by Thomas Sowell. And I educated myself in explaining why

Obamacare was not the answer and that it was just going to raise costs and reduce access, which took many, many years for people to figure out. But it's ironic because over the last year, people have seen the consequences because the subsidies ran out. And that's when people really felt the brunt of the cost of that. And over the years, people have seen their premiums go down, right?

Dr. Ronen Elefant, MD (03:39.18)

getting rejected for procedures that their primary care doctor thinks they need or even a specialist. You see it now all over social media, right? There's this plastic surgeon who does breast oncology, who puts out those videos where she's talking. Potter. Yeah, where she talks to the insurance company. And she's talking to what is considered her peer. And she's like, you don't know anything about what I'm doing. How are you rejecting these?

treatments. So people are paying a lot more, premiums are going up. Nobody feels like they're getting their money's worth and it's just a waste of money and there's a lot of fraud and abuse and we're seeing that now. Again, I educated myself on those things and I trained in general surgery. I went on to doing a fellowship in surgical critical care to be a trauma surgeon. And when I came out of fellowship, I

was moonlighting at different hospitals just to kind of make extra money. And I also wanted to operate a lot more than I was, you know, in fellowship, you're operating like crazy. All of a sudden, like the next day you're barely operating as like an attending surgeon. And I really wanted to, you know, hone my skills and get as much practice as possible. And slowly what I realized was that at every one of these hospitals that I was going to, I was learning different systems and how different places worked and what

The common denominator was what people did well at one place versus another. And I really enjoyed that because I'm kind of like a strategist. And for me, that was like learning a lot of strategy. Now, when I was in residency, that was the first time that it was exposed to the surgery center of Oklahoma, which was the first and only of its kind for many years. was a surgery center specifically built to have a bundled transparent

cash prices for surgeries. And you can go on their website and you can pick a procedure and you can see what the all in price is. And again, another dissatisfier for patients is that they get one bill, one month for the surgeon, and then they think they paid for their surgery. All of sudden they get another bill next month and they say, well, I already paid for my surgery. And they're told, well, this is for the facility. And they're like, what does that even mean? You know, so that

Dr. Ronen Elefant, MD (06:05.442)

did away with that. And the prices were also cheaper than most insurance plans or what it would cost at the hospital if you were paying cash. And for many years, I wanted to replicate that. I even went down to the Surgery Center of Oklahoma, met the person who started it, who's an anesthesiologist, kind of picked his brain. I live in Connecticut, where it's a certificate of need state. It's almost impossible to build a new ASC. There's two

major health systems. It's impossible to really create inroads in that kind of system. But I started coming up with this idea of like, okay, well, I was moonlighting for many years. Why can't I do the same thing and sort of create this moonlighting for elective surgery and replicate the Surgery Center of Oklahoma virtually in any state that I want by partnering with existing ASCs.

and performing bundled cash price surgery. And that's what I started doing back in November and it's been pretty successful. And I'm getting other surgeons on board to join the team. And we want to be in multiple states and we want to be a multi-specialty group as well. So I have some orthopedic surgeons, hand surgeons, and we want to offer that in many different locations, not just at the Surgery Center of Oglo.

Dr. Tea Nguyen, DPM (07:29.944)

So you started as a general surgeon, five years of training, then critical care fellowship training. And now you're saying, I'm not working with insurance. I'm going to do this instead. And you're recruiting, you're collecting other surgeons to provide surgical care, one price tag, and it's going well. This is so new to me. It's so exciting to be able to hear a surgeon speak on how they're making surgical care accessible.

And you were talking about how patients are, they don't know the price of things. They don't know that there is facility fee, anesthesia fee, surgeon fee, and then they get all of these divided bills and they get frustrated. And then maybe they weren't even financially prepared. Even when they have insurance, they have these deductibles. If they're not met, then they have those added expenses. And so we're solving a really big problem that we have here.

where nobody knows the price of anything or people are going out of the country because other countries have bundled pricing. They know the price of things and it's so much cheaper than what it is here. So I've got people who are just a flight away to Mexico or to Asia or whatever it is. But we can't seem to do that here in the United States. And it looks like you're leading the way in making that possible, which is exciting because I've been thinking about the exact same problem. When I first heard about the surgery center of Oklahoma and then Wellbridge in Indiana, I was like, how do we do that here in California? And I've talked to my local ASCs, the ambulatory surgery centers, and they're just not interested. And it's frustrating to sit in a place where you're divided. Morally, you know people need to have accessible surgical care. Logistically, it's a whole nother game that we're trying to play.

So take me into the world that now you're building surgical access. What exactly did you build and how are people accessing the surgeons?

Dr. Ronen Elefant, MD (09:34.198)

Yeah. So, let me take a step back and actually comment on a lot of what you said, because you're touching on a lot of different points. First, like you're saying, when you went to approach an ASC and they just totally didn't get it. I tried to do that in Connecticut also to approach an ASC and to say like, look, let's do what the surgery center of Oklahoma is doing. And they cannot get their mind out of the insurance. Like it's become such an embedded thing in

American health care, you know, and that was the point. The point is to make it like obfuscated, to make it difficult to understand, to make it so nobody knows what anything costs. And that, you know, again, the frustration that patients usually have is with the doctor, but that's misguided because we want the best for the patient, right? We don't even know what anything costs. Usually the patients are frustrated at the administrative level that we have nothing to do with, but they don't see those administrative levels, whether it's like insurance administration or hospital administration, they just want to interact directly with the surgeon. 

So one of the things that ACEs does is it makes that relationship back to what it needed to be, which is a direct relationship between the patient and the physician. And that means financial as well. But like the patients that we operate on,have like a white glove concierge service, they have direct access to our surgeons. you, when you see a consultation, we give our cell phone out to the patients. They can text us anytime, post op, pre-op, they send us pictures. It's the kind of service that people expect for the money that they're paying right now through insurance, which they'll never get, right? Because of all the layers. And actually just today, going back to something you just said also, just today I posted on LinkedIn.

about the reason that healthcare costs so much. I know, like everybody pontificates about why it costs so much and people talk about, well, we have to increase value. And it's like, well, it's very easy. Somebody else is paying through insurance for somebody else's care through insurance, like meaning you don't pay for your own care directly out of pocket, then nobody cares what anything costs and nobody cares what the quality is because somebody else is being affected.

Dr. Ronen Elefant, MD (11:57.27)

So when you take away the payment from the patient to the doctor, then nobody cares what it's going to cost. And they're willing to pay more because somebody else is footing the bill. And in order to reduce costs throughout healthcare, we really need to start paying out of pocket for the things that we can afford. I'm not totally against insurance, but healthcare insurance right now is not true insurance.

Health insurance needs to be catastrophic insurance so that you don't get bankrupt if something big happens, cancer, car accidents, something like that. But for most routine things, if you knew the price, you'd actually think that that's affordable. you know, well, like we see with direct primary care physicians right now, right? People are gravitating towards that because it's cheaper than most premiums for insurance. The patients get their money's worth and feel like they're getting their money's worth because of the direct access to patients.

So that's what I wanted to replicate with ACEs. Again, it took me a while to kind of figure out how to do that because while it's related to direct primary care, it's a very different model, right? The direct primary care model is like a monthly subscription. Obviously you can't do that with surgery, which is an episodic thing. But I figured, now, Surgery Center of Oklahoma or is it Wellbridge? Wellbridge, yeah.

Dr. Tea Nguyen, DPM (13:20.192)

in Indiana.

Dr. Ronen Elefant, MD (13:22.412)

Well, Bridget, there's like a handful of places around the country.

Dr. Tea Nguyen, DPM (13:25.518)

One in Denver, Colorado, also Smith Medical.

Dr. Ronen Elefant, MD (13:29.09)

Smith Medical, exactly. They're growing. Yeah. And Solstice Health in Wisconsin. So all these places are what I call hardware solutions, right? They have to build an ASC, and they replicate themselves like another surgery center in Oklahoma. So my idea was, as a mobile surgeon, since I've been traveling around anyways for many years, why not make this a mobile software solution, right?

There's 9,000 ASCs across the US. We don't need to build another one. And I don't need to put money down to invest in a specific location and have the headache of the real estate and the building and all that stuff. We can use existing ASCs that are not at capacity and just convince them that this is the wave. This is the wave of the future. And the truth is, we are seeing that even in Washington. The outlook is changing that independent

physicians are getting much more credibility and and favor and favorable legislation in Washington that I think if it continues, I think within the next 10, 15 years, this will be the way health care is delivered across the U.S. Going back to what I said about catastrophic insurance, I think that that's the important piece of this. And Obamacare actually made it illegal to just have insurance for catastrophic care. I was a couple years ago, I was looking for an alternative to health care because I wanted to put my money where my mouth is. And I said, if I'm going to say that our health insurance is not working, I'm not going to have it for myself either. And so I was shopping around. I called up a couple of insurance companies and I said, I want catastrophic only because most of the doctors I'm going to, I'm paying out of pocket anyways. They don't take any insurance.

And they all told me no until somebody said that's basically illegal by Obamacare. So they kind of built it into the system. So I changed. I don't have health insurance and I went with a health share, which is. Which provides for me that catastrophic coverage. And again, for those people who have a direct primary care physician, I would urge them to look at that as an option, as an alternative.

Dr. Ronen Elefant, MD (15:56.46)

That's much more cost effective and will serve the level of care that you're looking for with insurance that you're paying for out of pocket.

Dr. Tea Nguyen, DPM (16:07.384)

I just did the same thing. I signed up for Zion Health Share and it's really affordable for a contribution. is because it's not insurance, but you put this in the pot and then when the time comes where you can cash it out or use it, you have the freedom to choose the doctor, the surgeries. And now that we're moving more towards price transparency, we can actually be true consumers to shop around and decide what's best for us instead of some random person, you know, choosing for us. And in addition to that, I also have a DPC doc nearby, which has been really nice because you're right about following the money. If you pay out of pocket, you're more cognizant about where you spend it. You're much more mindful about your health. You're a lot more proactive because you're like, geez, I hope I don't end up with something catastrophic. You know, going to the gym is an investment. Paying for these health care services is all an investment ends up being out of pocket anyway.

So, you for our listeners here, if you get direct care, there are alternative options that is not insurance where you don't have to keep feeding the beast. You can actually step out and have a health share where if you're already generally healthy and you just need catastrophic care, that is a really great option. You're paying a low monthly fee. You're not bound to any particular network or system. And I remember coming out here in Santa Cruz where

I started with one OBGYN and then three had turned over within a year. And then now the whole system is slowly collapsing. And it's like, every time that change happens, I had to change doctors. But when you pay out of pocket to the doctor directly, the doctor directly, then it's just them, no matter what the circumstances are to your health insurance. So I think there's so many different layers to talk about in regards to how we can protect ourselves and our health, and how to maximize using insurance if you decide to have insurance and then lower your rates to just catastrophic care and then having your alternative paths with health shares and a direct primary care doctor or even direct specialty care doctor or surgeon for those episodic needs. So let's circle back to you as a surgeon. What are you doing? I see you on an airplane. You're flying around town. What is the model for you? Are you going to different facilities, different states to provide surgical care?

Dr. Tea Nguyen, DPM (18:31.51)

Or are you more on the administrative side now where you're the one that's contracting or getting doctors involved in this model?

Dr. Ronen Elefant, MD (18:38.702)

I do both. So I still love operating. So I got my pilot's license in 1999, way before I was even a doctor. And then I got a lot of my ratings during medical school. like instruments, commercials, multi-engine. And then I wasn't flying that much through the rest of like residency and fellowship. But when I got out and I was moonlighting at these different hospitals, I started flying myself to different hospitals. And I've been doing that basically since I got out of fellowship. So yes, I fly myself to different locations. So right now, ACEs has a facility in Wisconsin that we work with, one in Charleston, South Carolina, and one on the shore of Connecticut. And we are expanding fairly rapidly, probably pretty soon to Florida. I just had a call with somebody from Jacksonville.

And two weeks ago, I connected with somebody in Miami. And I think Florida, I think there's a lot of potential patients that like this kind of model and direct primary care that we could cater to. But again, we're mobile so we can go anywhere. And I have multiple surgeons in multiple states that are also willing to travel to the specific location. So the surgeons don't have to be local to the facility or to the patients, but I'm also part of business development.

Right? So like I'll use the airplane to go to the facility that I'm operating at, but I'll also go to, you know, find a new location and make the connections and, you know, talk to the DPCs, talk to the ASCs, convince them that this is better off, you know, we're all better off if we do it this way, because the only ones not making money off of our work are the insurance companies in this way. Like the patients end up paying less. the physicians, the surgeon and the anesthesiologist and the facility end up making more. And there's none of the headaches that come along with insurance with this model. And I think that when the ASCs or the physicians are exposed to this, they're like, wow, this is why I went into medicine. this is like, for me, that's the mission really. Yes, I like helping patients and I enjoy doing surgeries and I love interacting with patients and hearing that they have good outcomes. But I also...

Dr. Ronen Elefant, MD (21:02.574)

I'm driven by showing surgeons that there's a better way to practice medicine because I think we all went into medicine, not thinking that we would be employees of the health system and health insurance. Like I don't, I'm not a health insurance employee, right? I'm an independent physician and then, and my system and my company allows physicians to be independent and, and, and allow them to practice medicine the way they

thought they would when they first started medical school.

Dr. Tea Nguyen, DPM (21:34.318)

Let's take the perspective of a patient who needs your services. What is the access point? How do they learn about you or direct surgical care? Like what's the starting point for the consumer who needs surgery?

Dr. Ronen Elefant, MD (21:50.062)

So there's multiple avenues that they can find us through. Usually it's through a direct primary care physician, right, who makes a certain diagnosis, let's say hernia or gallbladder, and they would know about us and say, okay, I have this option depending on where you are, or if you want to travel to have your surgery, right? So patients travel all over to Oklahoma City. Now we're just expanding that geography, right? So if somebody wants to travel and they're going to travel anyways to Oklahoma City, now they can...

They can go to Charleston, can go to Miami, they can go to Connecticut, or they can go to Wisconsin. So that's one way. Another way is employers who are self-funded, who will steer their employees or their families towards a direct surgical care delivery model, right? And they may say, okay, here are five places across the U S where you can get it done. Wisconsin, the facility that we're working with in Wisconsin already has a great network of employers that they work with. So there's a constant funnel. I think that that's probably the best way to go. But I think over time, the direct primary care physicians will be the gatekeepers. It's just that a lot of them I've seen still for whatever reason steer patients to the hospitals for subspecialty care.

Hopefully we'll change that. So we're going to different conferences to make our name known and make sure that people know that we're an option as well. And then if for whatever reason the patient's doing their own research and they're Googling a place that they can get direct surgical care. So they're gonna see Solstice and Wellbridge and Smith and Surgery Center of Oklahoma that we're gonna be an option as well. And again, like I said, we're… software solutions. So any one of those places as a single facility, we're like at the moment, three facilities and soon to be many facilities.

Dr. Tea Nguyen, DPM (23:51.48)

I really love the idea that you're renting space. It's kind of like Airbnb or taxi drivers, which is now Uber, right? Like we're not owning the real estate. We don't have to rebuild what already exists. It's just so for me, that's fun because, you know, now we're being creative. Now we're using what we have and we're not reinventing the wheel. We're just kind of changing the system a little bit because I have friends who own their surgery centers, their cash base because, you know, their plastic surgeries, dermatology or in-house, like for me, podiatry, I've had to learn how to do surgeries in-house. But then there are some patients here in California who need sedation. I can't do that in the office. I know some states, there are limitations to that as well. And so they have to go to the surgery center. It's just more comfortable for everybody. So I had to learn how to be creative and solve a lot of problems because I like to do surgery too. And then, you know, there are cases where I can't do it in the office. And so we have to take it to the surgery center.

And there's always a hang up. The hang up is, okay, what are you going to charge me for the hour that I spend there? And they're still stuck in what is the CPT code for what you're doing? And I said, that literally does not matter because I'm paying you or the patient's paying you directly for the time. I don't need assistance. I don't need 50 different drapes. I know what I need to do. It just, it needs to be transferred from my office into your facility with anesthesia. And so they've overcomplicated this and for me right now, I don't have that access to a surgery center as seamlessly as I want it to. 

So I'm either gonna move or I have to build something else, honestly. Because this is so needed, but it has to be done with the right types of people who get it. They know that there's a problem and they're not just sticking their head in the dirt saying, well, that's not a problem we need to solve today. No, we need to solve it today. This is something that...

If a patient needs a hernia repair, they should not be waiting years for that. Bariatric surgery, they don't need to wait years for that either. There are all these different things. And I know a lot about general surgery because I married a general surgeon. And so I have keen insight as to what should not be waiting for years. Or like my friends in urology, they're waitlist for surgery, six months. What quality of life do they have during the time that they're waiting? That seems silly. It seems very unethical.

Dr. Tea Nguyen, DPM (26:07.63)

So for me, this is an urgent need to see it happen at a much greater scale. So I'm wondering what your efforts are aside from going to conferences to meet with people. How do you actually make these connections with the ASC centers? Are you cold calling them or is this through word of mouth through your connection?

Dr. Ronen Elefant, MD (26:24.878)

Both. Usually it's based on like needs, geographic needs of patients. So if we know that a certain geography is going to have the number of patients that are required for us to make it worthwhile to travel to that area, then we will reach out to the local ASCs. Usually physician-owned is easier to get into than like corporate-owned, although we've been surprised because we have had relationships with

corporate owned ASCs that were very open to us coming and success at one of those locations means inroads into, you know, whatever other ASCs they have in their network. Yeah. And, you know, once they, once we do like a day of surgeries there, they're like, wow, this is great. Right? Like this, we did not think that this could happen. And, and, you know, everybody loves the, how easy it is like, in one of the locations, for example, when I first went down to meet with them and explain to them what we want to do, they connected me with their scheduler, right? And she started talking to me about getting the insurance paperwork and all that stuff. And I said, you don't have to worry about that. And she was like, what? If I don't have to worry about that, that frees up half my day. And I said, exactly. You're wasting so much time and you have a person.

who literally is fully employed just to deal with the rejection and the pre-authorization and the paperwork and the CPT codes. And for me, like you were saying about the CPT codes, it was very hard for me to still deal with CPT codes, right? Because that's an insurance thing that they turned all these things into codes. Unfortunately, that's the language that we have to speak because it's a common language so we can all agree to what the procedure is. But other than that, there's no...

you know, no sign of insurance. Like we don't even, we don't even provide any paperwork to the patient that they can submit to insurance. We just say like, again, this is what you're getting. This is what you're paying. You're to get the service as promised. And that's all that's needed. So yeah, you know, a lot of these conferences will also have different ASCs or groups or whatever. So it's a lot of networking, social media conferences.

Dr. Ronen Elefant, MD (28:50.574)

cold calling. It's just word of mouth is also very big. A lot of people hear the idea and they're like, wow, I did not think that this could be possible. Which was surprising to me because for me I was like, okay, this seems reasonable. Again, like you were saying about using existing ASCs, I think as surgeons in general, we always try to economize on stuff, right? Like not wasting too many instruments and this and that and we always like, want, we're very careful with our time. And, you know, especially with, you know, my love of economics to me, was like, how can we make the best of what we already have? And there's 9,000 ASCs across the U S like they're not all being used. Like let's utilize those instead of investing time and money into building another one. 

And I don't want to even be fixed in one location, like not being fixed and using existing ASCs allows me the biggest flexibility to travel, right? So I can spend two days in South Carolina and then another two days in Connecticut and another two days in Florida, right? Because any one of these locations may not be able to support, you know, a five day a week surgery schedule. With this kind of framework, you have a lot of flexibility to just go where the need is as it's needed.

Dr. Tea Nguyen, DPM (30:13.454)

So tell me about the surgeon who wants to participate, who wants to be part of this. Do they travel to a specific state for a specific reason? Because most of the facilities that you're associated with are on the East coast and I'm over here on the West coast and I'm wondering, how can I do more? Like, how can I get my hands on my feet, you know, in the door do doing more because I'm limited by my location, right? Like my office is here.

The resources are here, but let's say I have a specific skill that somebody else needs somewhere else and I'm interested in going to that other place. How does that actually work in regards to payment and finances and all of that?

Dr. Ronen Elefant, MD (30:56.226)

So, you all our surgeons are willing and able to travel. It's not an onerous thing. So when I first got out of fellowship, I was doing some locum. So for me, it's always been like a normal thing to travel and for long periods of time, this requires travel, but not for a long period of time. Usually we'll schedule like two and maybe at most three days of surgeries at one time in one location. So you just have to be away from home for two to three days at most.

We realized that, you know, that's more sustainable than going somewhere for a week, both for the physician and from a scheduling standpoint. So we try to cram in as many surgeries as we can per day for those days. And we do have surgeons from all over the United States. Like I have a surgeon in Utah and one in Cal, who actually works in California doing locums. So right now we don't have facilities on the West coast because there is a facility, you know, at in Colorado Smith that we discussed, but I'm not opposed to opening a similar facility with, you know, ACEs in California if there's a need, right? 

And the surgeons can be anywhere. like I have a surgeon in Alabama and one in Indiana. They travel to Wisconsin. They're traveling to South Carolina. Yeah, it's sort of like. Locums, you know, for, guess for physicians, if they want to understand what it is, it's sort of like Locums without a lot of the headaches, it's physician owned. like, you know, one of the things that I hated about Locums is when I got called about assignments, they didn't know anything about the assignment itself. Like if I started asking questions, like are there PAs, what's the medical record, all this stuff, they're like, I don't know. I just know there's an opening. It's not like that at all. Like we, I'm a physician and I'm You know, I'm the one that sets up the facility and all the, you know, the patients and all that. So it's a very different feeling, but it's a similar mindset and there's no call. Right. So it's basically like locums for like elective surgery, without any call and a much easier lifestyle. Like the pre and post-op stuff is done via telehealth sort of like this. Right. So,

Dr. Ronen Elefant, MD (33:16.878)

You know, the physicians do that at home. They're sitting at home and seeing consults for a couple hours, like half hour visits, you know, or post-op 15 hour visits. I mean, 15 minute visits.

Dr. Tea Nguyen, DPM (33:29.934)

Post-op care, a lot of these surgeries, you need to remove sutures or infections in the things that need management. How is that handled?

Dr. Ronen Elefant, MD (33:39.352)

So that's why we have to have a really good relationship with the DPCs. Most of them are family practice trained and are comfortable removing sutures or lancing abscesses if there's an abscess from an incision. Anything more complicated, sometimes we steer the patients to the hospital. So like we had a patient with a retained common bile duct  stone after a cholecystectomy, they needed an ERCP. So it's something that we couldn't even do anyways. But a good relationship with the DPCs is crucial for this model to work. Direct communication and even phoning in by video to the visit at the DPC, right? To discuss with the primary care physician like, should we open this incision or should we just give it antibiotics and see how it goes? 

But it's been very successful. Again, the majority of patients have a great outcome. A very small minority have an issue and almost 95 99 percent of those patients issues can be handled by the DPC and then a tiny tiny percentage who need more care we have to send to like a local hospital which again for me as an acute care surgeon I see that all the time right like patients coming in with a surgical issue from a another physician who did the operation but we have to handle the complication again very small

minority of patients, but it's not unheard of. And you have a similar thing where patients get their cancer care, for example, at the Cleveland Clinic. They travel to the Cleveland Clinic. Then they go back home. If they have a complication, they have to get it locally. It's not, none of these things are novel, right? From the business idea to patient care.

I just put a lot of different pieces together that I've learned over the years, right? From the locums, from Surgery Center of Oklahoma, from working as an acute care surgeon. You just put all the pieces together differently.

Dr. Tea Nguyen, DPM (35:42.924)

Yeah, it's still logistics. So like if a doctor was traveling out of state, then they would have to have the state credentials, but also the ambulatory surgery center credentials as well, which I don't know if that's a fast turnover in your experience or not. Some places have like a temporary, like a one day permission. Like you can come here for one day and not have to fulfill the needs of the credentialing facilities, some places require like a minimum of six, 10, 20 cases or whatever per year, right? So these are all the just all the questions that give me a headache because I'm just like, why is nobody making this easy? What are we doing here?

Dr. Ronen Elefant, MD (36:20.394)

So that's the good thing about, you know, I have a great team and the back end office takes care of all that stuff, right? Like we, when we intake a new surgeon, we get all that stuff and that's it. You don't have to fill out paperwork for every one of these facilities. Our office takes care of the credentialing at every facility that we are going to work at or that that surgeon will work at. Licensing is just done individually. Luckily with the IMLC nowadays, it's much easier.

But as of now, I think there's only 35 states participating. I think within the next five years, all 50 states will be participating. And hopefully, one day, there will be a national medical license. Because taking out a gallbladder in Connecticut is no different than Pennsylvania. It makes sense in law, where the laws are different in every state. But medicine is just a moneymaker. a club.

Dr. Tea Nguyen, DPM (37:11.758)

Yeah, see that for MDs and DOs. I do not see that for DPMs, doctors of podiatric medicine. It's just a struggle. We are like the stepchild of medicine where we can do certain things, but we don't have the breadth of practice like a PA or an NP even though we go to the same school as a DO and an MD residency. Anyway, another story for another day.

It's been so nice chatting with you today. Is there anything that I've missed or you want to share about what you do in the direct surgical space?

Dr. Ronen Elefant, MD (37:44.43)

no, not really. mean, I think what I do want to share is that the more and more I talk to people in this space, I'm just really pleased with how everybody loves to share their experience and their ideas. Nobody's hiding stuff worried about competition because we all understand that competition will bring the cost down and we all are motivated by making care affordable.

And so everybody that I've interacted with, especially like Keith Smith that we both mentioned, was very open and helpful in helping me shape this idea into something real. I encourage people to reach out if they want to be part of the team or if they have more questions, then they can reach out to me.

Dr. Tea Nguyen, DPM (38:30.178)

Where do you think people should go if they're interested in creating something like this or building it with you? Where is like the networking opportunities?

Dr. Ronen Elefant, MD (38:40.194)

Well, I'm on LinkedIn. I have a website acesurgical.com. They can reach me by email Ronan at acesurgical.com. Yeah. And hopefully at these conferences for like the free market medical association or health Rosetta, you know, think a lot of, a lot of physicians probably know these organizations. If they don't, you should make yourself aware of it and go to the conferences with like-minded people.

Dr. Tea Nguyen, DPM (39:06.734)

Awesome. Thank you so much for all of your resources. I'll put all of that in the show notes and hopefully you get connected to people. Maybe even Mr. Mark Cuban will reach out and say, Hey, let's do this. Have you been paying attention to what he's been putting on LinkedIn?

Dr. Ronen Elefant, MD (39:19.622)

yeah, all the time. Yeah, I mean, I don't know why he's limiting himself to, you know, drugs, right? Like I'm like, whatever you're saying, you can apply to medicine in general.

Dr. Tea Nguyen, DPM (39:30.306)

He has talked about DPC, so I'm very interested to see if he's gonna help out the surgical folks too. We'll see. Time will tell. Thanks so much.

Dr. Ronen Elefant, MD (39:39.628)

Thank you.