Dr. Steve Borene is an anesthesiologist with more than 20 years in practice, a Marine Corps veteran, and the co-founder and CEO of Renovo Health, a direct-pay surgery and medical infusion center in Wisconsin that posts, bundles, and holds its prices. He knows legacy hospital systems from two decades of practice inside them, holds a master’s degree in healthcare delivery science from the Tuck School of Business at Dartmouth, and co-leads the Wisconsin chapter of the Free Market Medical Association.
Patients and employers rarely see what drives the price of a procedure, from administrative overhead to the incentives of every party standing between them and their care. This conversation follows Steve’s path from hospital operating rooms to a surgery center that quotes prices 60% below legacy systems, including the canceled pre-op EKG that showed him how much of the system runs on revenue generation. He explains where Renovo’s savings come from and why keeping fewer parties at the table leaves less room for hidden incentives and under-the-table deals. As the funders of care, employers hold the money and the influence to steer patients, and Steve makes the case for using both. Listeners walk away knowing why direct-pay care costs less and how employers can give their people a reason to choose it.
In this episode
- A self-pay patient who could save more than $10,000 by waiting one more week for her procedure at Renovo, and a man whose employer refused to cover a $3,000 pain procedure
- A treatment one company pays over $40,000 a month for, against Renovo’s offer of under $2,000, and the case for sharing those savings with the patient
- How buying a surgery center and firing the administrators cut costs by two-thirds
- Copying competing medication suppliers on the same email and switching a general surgeon to a trocar that costs $6,000 less
- Rebates, kickbacks, TPAs, brokers, and care navigators paid a percentage, and how to find partners with nothing to hide
- Working with about 180 employers and reaching hundreds of thousands of lives through partner groups
- A canceled pre-op EKG, two weeks of follow-up emails, and the trip to Dr. Keith Smith’s Surgery Center of Oklahoma that led to Renovo
- Accounting for every cost with patients, down to the $50,000 lights in the operating room
- Moral injury among physicians and why “I don’t know what it costs” sounds to patients like “I don’t care”
Transcript
Andrew Gordon: Welcome to The Price of Healthcare. I’m your host, Andrew Gordon. On this show, we sit down with the executives, influencers, and people working to build a functional healthcare market. Every episode, we’re unpacking what’s broken, what’s working, and what it takes to buy healthcare with informed choice. My guest today is Dr. Steve Borene. Steve is an anesthesiologist with more than 20 years in practice and the co-founder and chief executive of Renovo Health, a direct-pay surgery and medical infusion center in Wisconsin that he built with his partner, Josh Johnston, who is also an anesthesiologist.
Andrew Gordon: Renovo posts its prices, bundles them, and holds them across general surgery, gynecology, urology, interventional pain, gastrointestinal procedures, dental restorations, and infusions. Before medicine, Steve served in the Marine Corps. He earned his medical degree at the University of Minnesota, completed his anesthesiology residency at the University of Iowa, and earned his master’s degree in healthcare delivery science at the Tuck School of Business at Dartmouth. He also runs an anesthesia staffing company, and he co-leads the Wisconsin chapter of the Free Market Medical Association. What got my attention is that Steve does not just quote a price. He reads an employer’s claims line by line and tells them what actually happened to their people. Steve, welcome to The Price of Healthcare.
Steve Borene: Thanks, Andrew. Appreciate that. Appreciate the opportunity.
Andrew Gordon: So as part of the warm-up, you were sharing a couple of recent stories with patients. I’d love to just have you unpack and dive into one of those recent examples for us.
Steve Borene: One of the things that we were discussing is a woman who’s suffering from a gastrointestinal issue that she’d been dealing with for some period of time. And she was recently encouraged to go into one of the legacy systems to go ahead and have some procedures done that we offer at Renovo Health. The woman had the opportunity to get a procedure done with us or her already scheduled procedure. So she can get in, in three days or seven days. And she’s been dealing with this for a while.
Steve Borene: Either option would have some advantages. Getting answers sooner certainly can make a difference. Waiting the week to be seen with us would probably save her in excess of $10,000. And she’s somebody who’s going to pay herself. She’s not part of any other health group; the cash out-of-pocket makes a difference. And so what’s unique with her is she and her family have decided that the extra cost is worthwhile to them.
Steve Borene: Now, people don’t get that decision in much of American healthcare nowadays. It’s a little frustrating for me because I feel like we could really offer her benefit and it would probably be just as good. But what’s so critical here is it’s her choice, right? There’s so many things that we have in medicine now that isn’t our choice. Somebody else has decided. We’ve got a gentleman who was going to have a procedure done with us, but his employer, or his coverage plan, refused to cover one part.
Steve Borene: He’s having three procedures. He’s having a ganglion cyst excision. He’s having an umbilical hernia procedure done with us. But there was a third procedure that was elective regarding some back pain and an interventional pain procedure, and his employer has said no. Well, he was going to pay out of pocket to have that done, a $3,000 procedure. He said he just can’t get the money together right now.
Steve Borene: And so instead, he’s going to go through physical therapy, some other things, which he’s done. He’s been dealing with this for quite a while, and he had the same procedure we’re offering done three years ago with good benefit. He felt like that choice wasn’t his because he’s through an employer that works with us partially, but not entirely. And so he’s at a bit of a disadvantage there trying to balance between the legacy system and what we do in the direct realm. So he’s frustrated. He’s going to get two of the three things that are bothering him taken care of.
Steve Borene: But he’s very frustrated with the whole situation. This other woman has one issue, she’s got all the information, and she’s making a decision, not one that everyone would make, but she’s making a decision that works for her. Now, that’s what we’re trying to do. I’m not here to be the healthcare provider for everyone. We want to be available for everyone. We’re an open book.
Steve Borene: We’re easy to see what we offer. We don’t offer everything for everyone, but we want to be that option that people get to choose or not choose. And it’s reasonable not to choose us for things. If there’s a surgeon who’s worked on you before and you feel like they have a knowledge of you that is different or maybe even superior to what our team has, it might not be unreasonable to go ahead and continue that relationship. But it has to be based on a relationship, number one.
Steve Borene: And number two, it needs to be something that advances your own healthcare position, right? Something about what you bring to the table. It might be financial, it might be medically related, it might be travel, but people deserve the opportunity to go ahead and have all those portions of their care determined by them. And if somebody else is paying, if somebody else is funding their healthcare (I know that’s one of the things that we’ve talked about before, the funders of healthcare), if those people want to play a role, which they should because it’s their money, that’s the place where they can incentivize, where they can influence people.
Steve Borene: We had another patient that we talked about briefly too. They’re paying over $40,000 a month for that person to be treated. We offered to provide the same treatment for under $2,000 when we built our prices together, so one-twentieth the cost. And we heard back from the company that the patient’s not interested in driving. And my thought to that company is, well, maybe they should try to make it worthwhile to that patient. That patient maybe is saving that time.
Steve Borene: They said, would you like to drive this extra hour on each trip, every month, for this medication? Well, there’s some actual money. Now, this person is dying of a devastating disease. This medication is going to prolong their life. That’s the goal.
Steve Borene: I’m sure they have different priorities and money is maybe not the top priority to them, but it’s an extra $480,000, well, I guess $450,000, that this company’s going to spend on this person’s healthcare. I’m wondering if there’s maybe a way that they could have a discussion with that patient and say, hey, can we split this with you? If we got $200,000 more in your pocket over the next year, it would save us the same money. It would save you. You’re valuable to us.
Steve Borene: We want to go ahead and show value. We want to make sure you get this treatment. We want to encourage all that. But if there’s a way we could pay you for that, which helps us, just like we would if we were getting steel or fuel on a bulk fuel discount or whatever. Is there a way we can work with you for that? And maybe the patient would be empowered.
Steve Borene: Maybe their last year on earth would be more worthwhile. Maybe they would buy a Corvette, but maybe they’d feel like this is helping to put money aside for the family I won’t be able to support when I’m gone. There are lots of aspects that can be addressed if people have honest conversations and if they have the opportunity. And that’s what we want to do at Renovo is bring those discussions to the forefront. We want people to be aware of different options that are there, and we want them to not be taken advantage of financially all the time and give them the decision back like they have in every other aspect of their life.
Andrew Gordon: I appreciate you sharing all that. And I do want to double-click into the savings, being able to help people make an informed decision. Talk to us a little bit about where you see some of those savings coming in from. Obviously, the services that you guys offer are coming in a lot lower than some of these other providers and systems that are out there. Talk to us a little bit about where you see some of those major levers that you’ve been able to take advantage of in terms of being able to get people a really competitive and fair price?
Steve Borene: The overview of what Renovo is: my partner, Dr. Josh Johnston, and I bought a surgery center, and the first thing we did is fire the administrators and found that the cost of everything is two-thirds less once we do that, once it’s just caregivers. I mean, I still got to pay electricity and insurance, and I do have an accountant. I got a lawyer. We pay our staff. We still have to get IV supplies and medications. And there’s a lot of air conditioning and heat that goes on in our part of the world.
Steve Borene: We got to have the setting just right for the operating rooms. All those costs still exist, but we’ve taken care of so much of the overhead by removing so much of the useless and, frankly, onerous administrative burden. On our website, we quote 60% less than legacy systems. Often the reductions are more than that. If somebody comes in and they’re getting medical infusions, we’ll work with them, find the best options.
Steve Borene: We’ve got a few different sources for where we can find medications. I’ll put emails out and I actually CC the other groups that I’m working with. So it might be four different companies that I source medications through and I tell them all what I’m trying to get: which one of you can give me the best? So they can see who they’re competing with. And I want to see the response from them. It’s interesting to see which ones will reply all, which ones will go offline.
Steve Borene: And it’s been refreshing, because over the couple of years that we’ve been doing this, I’ve got more people that will just reply all: this is what we can do. Oh, we can do this. And sometimes they’ll have conversations; they’ve got to be careful because they don’t want to conspire together, of course. But I think it’s worthwhile for them to see what else is out there. And also for them to know that we’re just honestly looking at what the best options would be. People work hard. I’ve had some arrangements where they’ve lost money on a particular instance that they provided something to us: we got it for you last month at this price, but we’ve got new tariffs we’re struggling with.
Steve Borene: I can offer it to you for this price again because we think we’ll have a workaround going forward, but I may not be able to hold that. Well, when they have loyalty to us, we show loyalty to them because we’re building those relationships. And it’s been that kind of opportunity, finding people who want to create better opportunities and better efficiencies, that has let us continue to be reliably one-third the cost of other people, whether it’s a surgical procedure or an infusion or a colonoscopy.
Andrew Gordon: So you would say, as I’m hearing you speak on those points, Steve, a lot of it comes down to administrative markup, some of the overhead, and a lot of those components are where there’s real room and opportunity for people to be able to save some money and operate a lean, mean Six Sigma machine.
Steve Borene: Well, yeah, that’s it exactly. And it’s not just that my partner and I are mopping the floors, which we’ll do, or cleaning the toilets or doing whatever. All our staff does all of that. That’s part of it. But the reason we do that is the same reason why I will doggedly go after one supplier or another to negotiate a 10% decrease, or if I can buy something in bulk, or if I can anticipate. We worked with a general surgeon getting ready for cases next week, and he had asked for a particular trocar for doing laparoscopic procedures, a piece of equipment that allows him to use the laparoscopic equipment.
Steve Borene: And we asked him if he’d be willing to accept a different piece of equipment instead because that particular one is $6,000 less expensive. And he said, oh my goodness, I’ve used those for years. Absolutely. That is just fine. He said, the other place that I work moved on to these others, so I thought that would be exactly what I’m used to, but I’m totally used to the other option. And so it ends up coming back to the mentality of finding every opportunity because it matters to the patient.
Steve Borene: And when it matters to the patient, it matters to me and my partner and our whole team. And we never quit, right? Where we are right now isn’t where we’re going to be next year because we’ll have another opportunity to make another friendly business arrangement with someone else that can offer something in a more effective manner. And we will keep pursuing that. Whereas in the legacy system, there’s no benefit to them, right? They’ve negotiated a price which is unrealistic anyway.
Steve Borene: It wasn’t based on the cost of the goods that they’re using to provide that service in the first place. And the administrators that could go in and do these same arrangements, all they’re doing is upsetting the apple cart at that point. And maybe their supervisor is the one that negotiated that deal and now they’re going around it, right? They’re not going to make friends. There are going to be emails that come out of that. It makes their life harder to try to do something better. So they learn real early in that job not to even look into it, to leave that up to someone else. And everybody loses when that’s the case.
Andrew Gordon: I think one of the most extraordinary things that I’ve noticed about you and the place that you’re running is really being able to advocate not only for patients and deliver and be front and center on doing that care, but also look at the cost. Like you said, understanding the suppliers, the materials, everything that needs to come into the picture, and letting them know that you feel an equally important fiduciary responsibility for how much they’re spending, not just their time, not just lending you their health to be able to help repair and trusting in you for that.
Andrew Gordon: There’s a lot of incentives that I feel like are certainly in the wrong direction in this industry. And I think one of the questions I’m sure a lot of folks are having is: talk to us about the incentives for you with where you sit. Talk about the incentives for coming in at an incredibly good price, being able to see the total person. Walk us through what that looks like. What should we be aspiring to for aligned incentives in healthcare as somebody that practices it every day?
Steve Borene: Right. And the key word right there is aligned, right? Find out how we can align with mutual benefit is the whole goal here, right? Or it should be the whole goal. And it isn’t universal that that’s the case. In fact, we’ve got plenty of people who are kind of in this pseudo-free market transparency space where they talk a good game.
Steve Borene: They’ll be the ones, and I won’t lose a follower over this because they’ll still want people to think we’re following each other or something. But we’ll have people who, when we espouse something that saved or benefited a group or an individual, they’re right there, way to go, Renovo. You guys are amazing. And then behind the scenes, they’ll be telling us that we should raise our prices because is there a way they could get more people to us if we gave them a special deal, right?
Steve Borene: Everyone wants a special deal, and everyone’s been conditioned to go ahead and get one. You call them rebates or kickbacks or bribes or extortion or whatever you want. Some put you in prison, some don’t. But there’s not a whole lot of difference one way or the other, right? So trying to figure out who is getting something on the back end or under the table is so much a part of what we’ve had to deal with, and how many people have wanted to deal with us under the table is really, it’s gross, but it’s also not surprising, right?
Steve Borene: So trying to identify all that, how do you find people who are aligned? Well, you limit the number of people involved is the easiest way, right? If I’m taking care of someone, we either have people that come in directly and work with us, or they work with us through an employer that is a funder of their healthcare, right? That’s pretty much the only way people come to us. And so if they’re paying themselves, now they’re aligned with their own best interest.
Steve Borene: If it’s an employer and they work directly with us, they’re aligned. It’s them and their employee or covered life and us. This is a small group. We can be aligned easily. As soon as the plan sponsor, the employer, brings in a group to oversee, whether it might be a TPA, right, that’s supposed to ease the way that they can keep them compliant and fit within their plan documents to go ahead and manage everything.
Steve Borene: Well, if that TPA has a different goal, maybe they aren’t perfectly aligned. Maybe their alignment is to make money, which isn’t unreasonable. If they’re providing a service, they should certainly do that. But what if it isn’t to make it as efficient as possible for that employer? Or what if there’s a broker involved that also wants to get paid, who can also get paid a little bit more if they use this other system? So it’s a care navigator that gets paid maybe a percentage, right?
Steve Borene: There’s so many different incentives that are under the table. The best way to limit that is to limit the number of people at the table, and that’s what we propose to do, right? That’s the direct care, whether it be DPC, direct primary care, direct specialty care that we offer. How do you keep it as direct as possible? I’m trying to think of the number of employers. We have about 180 groups right now, 180 employers that we work directly with.
Steve Borene: We have access to several hundred more, actually hundreds of thousands of lives through other groups that act as indirect providers of patients to us. So it’s not as perfectly direct as we’d like it to be, but those are some groups that offer some real benefit: they can negotiate with stop loss. They can go ahead and cover the parts of care that we don’t cover because people still have a ruptured AAA that they have to get immediate care for. So they still have to have access to some other types of healthcare.
Steve Borene: So having those other groups is critical, but it’s about finding those partners that can do so much of that work to encourage direct relationships. Some of these groups don’t make anything from me directly from patients coming to see me. And those are the best ones. And those are the ones that send the most people to us. And if they go to an independent cardiologist who’s just down the road or just up the road from us, they also don’t collect anything from those people. There are other groups that do have a little piece everywhere along the line.
Steve Borene: And it’s worthwhile for employers to find out who can I have a relationship with, or individuals to say, who can I have a relationship with that is going to be honest about that, who isn’t ashamed? I wouldn’t be ashamed if I had a group that could bring somebody to me and I could integrate that group, integrate Renovo into their plan, and guarantee that everybody that goes to a primary care doc and gets referred for one of the procedures that we offer, if they guaranteed that all those people would find our group or at least be offered the benefits of our group, that’d be worthwhile paying that person something.
Steve Borene: Maybe it’s worth 5 or 10% to go ahead and do that, but that group should be confident enough that what they’re providing is worth telling that person, I’m going to take 5% of the cut because it’s that valuable and it’s going to benefit your group. And we ought to be able to show that. And I’m fine with that. But they need to be upfront and honest. And there are people out there that are doing that now. And that’s a new thing.
Steve Borene: That’s a new thing in this space. And that’s exciting because there are people finding out there’s a broker that we’ve worked with some. He isn’t from real close by, but he’s encouraged people. We’ve had some patients come to us outside of their plan because it’s better for them. We’ve had some employers contact us from outside of the plan because it’s better for them. And he doesn’t play any role. He just connects us and says, you guys take it away.
Steve Borene: If you can take a little bit of the money off the table, that’s going to be better for you guys, and I know you’ll want to keep working with me. And that’s an easy way to keep doing business with people for the rest of your career, right? That kind of approach.
Andrew Gordon: Absolutely. Absolutely. I do want to ask as well, just relative to markup in medicine, making a meaningful difference in the lives of patients, folks saying, hey, you know, there’s a lot of expertise that comes into this. There’s a lot of trust and other things. How do you balance and sort of see that narrative? You know, certainly there are businesses that need to be run. People need to be able to make some money. There can be a margin, but how do you guys approach that? And what does that look like when you just think about the fiduciary responsibility, serving patients and employers the best way possible, but then at the same time being able to recognize and appreciate and be respected for all the high-quality care and work that you’re delivering?
Steve Borene: Sure. Yeah, great question. And it leads to, I mean, turmoil’s too strong a word, but that’s where stress comes into the business, right? We want to stay in business going back to the old mantra, no margin, no mission, right? How do you find the balance there? And one thing that’s been really exciting about working with my partner, Josh Johnston, is that he and I are both principled and share the same values in what it is we’re trying to deliver.
Steve Borene: So for us, it happens to be our Christian faith and the goals that we’re trying to make things better here, contribute in a way that we can here, and serve as an example. But we don’t feel like our rewards need to be here, be earthly rewards. So for us, it’s something beyond that. I think it’s hard to not have some other goal, making sure that money isn’t your lord, right? It doesn’t have to be exactly the way we’re doing things, but it’s how it has to be for us.
Steve Borene: So I think people have to look beyond the immediate: what is their impact going to be? And I think there are a lot of ways that people will find that. I didn’t get into medicine for altruistic reasons. I didn’t get into medicine to help people. I didn’t get into medicine to cure. I thought that was all fine.
Steve Borene: I thought it was a reasonable way to make a living and support a family, but I like the challenge. I like the physiology. I like the science. I like a lot of the other things, and it seemed like a really productive way for me to use the things that I liked that was going to be useful for society. And that’s all true. And I think that’s fine.
Steve Borene: But it’s been just later in my career after decades of this that I realized there was a connection with people that was missing when I just produced things in that manner. And it was things that didn’t matter. It’s not a lack of connection in my own practice. It was something that I had with each patient I took care of. But my interaction as an anesthesiologist ends. I’ve got 10 minutes to convince them to trust me that every bodily function that they have will be well taken care of by me while they’re rendered unconscious and somebody else violates their body with a scalpel.
Steve Borene: That’s pretty neat, right? So that’s been a fun challenge for me. But to have that long-lasting impact on people through a system wasn’t there. And I couldn’t get that in the legacy system. So for Josh and I, people can see that, or we think they can see that. We hope they can see that, that we’re looking beyond just providing care, but that care has to be central to everything we do.
Steve Borene: We’ve got to be able to connect with people on a professional level, on a skillful procedural level with proper medical therapies. We’ve got to do all the things that we would do within the regular system. But it turns out it’s actually easier for me to do that here because if I need something, I just go get it. Or I talk to my partner and I say, this is an important component for us taking good care of patients. How do we incorporate that here? And that’s been a really useful approach for us.
Steve Borene: We’re grounded in the same things. We see things the same way. We aren’t led by the bottom line. We figure that if we take good care of people and are given enough time to do it, it’s going to work out in the end. And that’ll be something worthwhile for us to be able to pass on to whoever else might be paying attention.
Andrew Gordon: You shared that as part of the healthcare delivery science degree that you got, direct care didn’t come up. I know you spent time with Keith Smith, the Surgery Center of Oklahoma, Free Market Medical Association. Walk us through a little bit about what it means to be direct care. What does that look like for people who are really interested in pursuing a similar future? Some of the mechanics in terms of being able to transition from where they currently are. I mean, tell us a little bit more about this and then breaking down, you know, does this mean no contracts with insurance companies? Like, kind of walk us through a little bit of the soup-to-nuts simplicity of it.
Steve Borene: I was 20-ish years into my career and I felt like I wasn’t communicating with administrators in the hospitals. I had ideas that I thought would be beneficial for patients, for my lifestyle, for my partners, for the other people I worked with and better for them. And I felt like I couldn’t speak the language. And so I thought maybe what I need to do is get another degree. And so I had an opportunity to pursue a master’s degree in healthcare delivery science because it was named exactly like what I wanted to do: healthcare delivery, right?
Steve Borene: I wanted to become an expert at that, and at a great program. Tuck Business is just a great place to be connected with brilliant people who were real leaders throughout the market. And it really offered me a lot that I hadn’t anticipated. Well, I went through the program and we did do some understanding of the language that the administrators were talking about, but I didn’t feel like it was adding for me what I was looking for because I had an expertise at healthcare delivery that they didn’t.
Steve Borene: It turns out that I already knew what I needed to know by being in the operating room and taking care of patients and touching people for 20 years. And what was missing was that this was just a component of a big system. So now I understand the healthcare system of the nation better, and that it’s a revenue generation tool that just happens to have a little bit of medicine down here in the corner. I was thinking that this was one big system and it’s the bug and the feature difference.
Steve Borene: The bug is the healthcare. The feature is revenue generation. And a lot of people will still say the system’s broken, it’s got to get flipped around, or we have to fix the system. And to which I say, it’s an elegant, beautiful system. If you were going to create a way to go ahead and extract value and revenue from a mass of the population and have them keep coming back for it, I mean, it’s beyond Orwellian, right? Bradbury and Rand wouldn’t have even come up with something this brilliant.
Steve Borene: It’s a beautiful system for doing that, but it hurts people. It’s that thousand cuts, right? They don’t realize they’re being hurt right away. And we’ve gotten to a point now where it’s, I think, moved so far along and it’s gotten so big that enough people are talking about it, and it is being recognized. And that’s something that I didn’t get within the regular system. It never occurred to me. It was only through talking with my partner, Josh.
Steve Borene: He had been reading Marshall Allen’s book, Never Pay the First Bill, just when they were first starting the project there and all his other work. And it was through that kind of direction that we became aware, and Josh is the one that first encouraged us to pursue the Surgery Center of Oklahoma. And Keith, Dr. Keith Smith, was able to put a phrase onto the difficulty, on what it was we were suffering. So Josh and I had left legacy systems. We began doing some traveling anesthesia work.
Steve Borene: We were working in a larger city, got control of our schedules, had more accountability in our practice as far as our own involvement in it. We were able to satisfy our financial needs, but we still didn’t feel right going in. I think I’ve shared before an instance where I had a patient who had run a marathon. I was taking care of him just a few days later for an inguinal hernia repair, and we were delayed in the operating room because his EKG, his standard perioperative EKG, wasn’t performed.
Steve Borene: Well, I knew everything that I needed to know about his cardiac function because he ran a marathon quicker than I’ve ever run a marathon. And he looked great and he did well. I didn’t need that information, and I was the only doctor that was going to see that information, but they were holding the case up to get that, and I didn’t want to cancel the order. I was told it was a part of the perioperative protocol. I asked if we could bypass it, and they said, if you want to cancel the order, you can.
Steve Borene: And I’m not in the habit of canceling other doctors’ orders, so I contacted that doctor who at 7:05 in the morning, credit to him, was able to be reached. He said, no, I won’t cancel it. He said, they’ll ding me. I’m required to go ahead and do that. That’s part of the program we put together. And unless I have a really good medical reason, and I don’t in him, to go ahead and cancel it.
Steve Borene: And he said, but by the way, what’d he run the marathon in? He knew the patient. I told him his time. He said, oh, wow, that’s great. Yeah, he’s in great shape. You won’t find anything.
Steve Borene: So he already knew that, and that’s not what he was ordering for, but he felt compelled and was compelled by the organization he was a part of to do that. I said, do you mind if I cancel it? Because I said, I’ll cancel it. He’s like, that’s fine, that gets me off the hook. That’s probably the best thing for him. So I canceled it.
Steve Borene: Well, before we were done with that case, I had emails and actually one phone call from a perioperative nurse manager who said we varied from the protocol and she needed an indication. I had a cardiovascular services manager who wanted to know why I canceled that. They had a tech to do the EKG that was there scheduled for that purpose. And also the cardiology service wanted to know why we had one less. They have a cardiologist who had time dedicated to read those EKGs. If I could explain to all of them why I altered the protocol, what was the medical indication for that?
Steve Borene: And there wasn’t a medical indication to have the test in the first place. So I said I didn’t need it. I had all the information that was necessary to safely care for the patient, and that didn’t matter. Well, the cost to the patient was going to be in the hundreds of dollars. There’s more revenue being generated. That’s all the system cared about.
Steve Borene: And I ended up for the next two weeks having emails coming to me from different people: help me understand why you canceled this. I was exhausted. I thought in my mind, this bothers me, but in the next opportunity, I’ll just let them do the EKG. They beat me down to that point where I was going to be like, forget this. I’m not going to fight this all the time because it turns out they were doing that on all my patients. They just had it done in time and it was finished before I saw them, and I didn’t have time to stop them.
Steve Borene: So I went through this fight on one patient because that was delayed. That tech took longer on a previous patient and it slowed things down. It came to my attention. I found out there were things all throughout the system that were happening like that, and I felt dirty. And so Josh and I were both frustrated, and that led us to the Surgery Center of Oklahoma, and we actually made a trip down there. Hopped on an airplane.
Steve Borene: We had to drive to Chicago, which for Wisconsinites isn’t always our desired approach. So we drove to Chicago and took a plane down to Oklahoma City. Saw a simple system. Looks just like our place does now. It didn’t have all the machines, all the computers, everything that was extracting wealth out of the system. It had basic medical tools provided to basic medical providers to take great care of people.
Steve Borene: And after we saw a couple of cases done, we sat down with Dr. Smith and he said, what you’re doing, what you are when you’re inside the legacy system is you’re an accessory to a crime. And that laid on us heavily because that’s what we felt like. We felt like we weren’t committing a crime. We were taking the best care of the patient. We were doing all the things we could with the tools we had. But this is a system that bankrupts people.
Steve Borene: It harms people. It gives them exposure to medical procedures they shouldn’t have that can hurt them or that aren’t needed, and never for their benefit. It benefits somebody else remotely. And when we were able to put that phrase on it, it became clear to us that Renovo is the way that we had to go. We needed to try and do the same thing, and so that’s what Renovo was born out of with that full idea. So every time we see a patient, we want to build into that.
Steve Borene: We want to justify every single thing. So I do it not only with cost, but also with time. One of the things we’ve talked about previously is how quickly we can get patients ready for a procedure. Right? If they come into the legacy systems, they sit down with a computer and the nurse has 84 questions to go through to go ahead and collect data so they can go ahead and plug it into their EMR so somebody can turn it into a data profile so they can try to figure out how to extract more.
Steve Borene: Can they get an extra diagnosis? Can they add something else into the system that justifies all the resources they’re pulling from people? We don’t do any of that. We aren’t going to ask you. We hope that you’re eating well. We’re going to get to know you.
Steve Borene: We’ve already spoken to you multiple times before you came in. We already know who your spouse is, who your kids are, who drove you in. We already have that information because we put that investment into them, usually over the phone, sometimes through personal visits. We don’t need to get additional information and feed it into a computer so that we can try to generate some data that gets utilized by who knows who. We just focus on the patient. So we ask them the questions that are pertinent to the intervention that we’re going to go ahead and offer, start their IV and take care of them.
Steve Borene: So we save time there. And I’ve got to do that because every time I interact with a patient, I’ve got to be able to say, all right, you’ve got 7 cents of your visit is going to the lights in this room and the electricity. I can’t break it down quite that far, but I can get pretty close. I can tell you how much is going towards my accountant. We need to have malpractice insurance because we’re required by law, and that’s what protects us and patients.
Steve Borene: I need to have a new scalpel. I need to have IVs. I need IV fluids. I need medications. I need the anti-nausea medicine, and I need to send somebody home with a pain pill. I need lights.
Steve Borene: The lights in our operating room cost $50,000. That’s ridiculous. I have a generator out back. If the power goes out in the middle of a case, it kicks in over 300 kilowatts. We could do the entire side of Lake Michigan where we sit if we had a big storm. We’ve got to cover all these expenses, and I’m not ashamed of a single one of them.
Steve Borene: And I’m happy to go ahead and talk to patients about what it is I’m charging for. That’s what I need to do. I need to be able to have that relationship with every patient, with every funder, and the people that come in our door. Once they come in once, they’ll come back. They’ll bring their family members. We’ve had people who came in through their employer, and their sibling isn’t covered through the employer, but the sibling comes in and pays cash because they’re like, this is where I want the care.
Steve Borene: This is where I want to come in. So once we get people in the door once, they see that. So it goes back to what is the driving force. And if the driving force ends up being the care provided to a patient, everything else is easy to justify, easy to explain. I’m not ashamed of any of it. I’m happy to show the books, right? I would challenge any legacy system to go ahead and do that.
Steve Borene: I don’t think the administrators have access to all the books at most of the places. I think they’ve got silos all over and they’ve got things hiding here and there. Some of it they don’t even intend to hide. I’m sure there’s just so much data that they bring in and bring out, but they keep churning the money machine and that ends up being what drives what they’re doing. And it’s different from what drives what we’re doing.
Andrew Gordon: For sure. You’re showing, you’re demonstrating value. People are coming back as a result of that. You’re able to get amazing referrals from the patients themselves who are talking about how great the care is you’re delivering. I also heard you talk about moving away from traditional legacy protocols that may prioritize or put profits ahead of, at the expense of, the American people and the patients that we’re looking to serve. So I do think that from those volume expectations or standards, we need to shift, move to value expectations.
Andrew Gordon: You had told an excellent story in one of our earlier conversations about the level of trust that you gained with a patient when you said, you know what, I don’t actually think that we’re going to have to have this surgery that you were scheduled for, or I’m not really sure that we need to do this and here’s why. And I think that explainability and being able to hold their hand through it and walk through something that could be intimidating being in front of a doctor. It could be an unknown in their life. And you’re saying, I’m here with you. I’m going to help shepherd you through this process. It’s an incredible thing.
Steve Borene: Well, thank you. That’s perfect. We’re on the path with the patient, and that makes all the difference. The patient you mentioned was a lipoma patient that came in, and had they gone to the legacy system, they would’ve — and I’ve seen those cases. I spent years in that system where we would look through, we couldn’t figure out exactly what we were going to do, but we were there and we were going to find it. And we’d go ahead and do the lipoma excision, right?
Steve Borene: You’ve got a mass on their back that’s caused a problem for them. Maybe they’ve had some imaging before that shows something was there. Well, they enlarge, they shrink. Sometimes they become less of a problem and they can be pretty small and hard to find. And we put a lot of effort in to find that. We used ultrasound.
Steve Borene: We went back and forth. I’ve done that, or I’ve seen that done with the legacy systems, and they didn’t find anything, but they said, but this is bothering the patient. Let’s take a look. I don’t know what that means. And I was involved with that case. We put it on hold.
Steve Borene: I got moved into another case in a big system, and I thought that patient was going home. And I saw later in the day that one was in the recovery room. And so I’m like, you know, what are you still doing here? Because I had finished my other case. They said, oh yeah, they went in and they took some tissue and they think they might have gotten it. I’m like, well, you know, hope so.
Steve Borene: And I happened to review the pathology report later and they didn’t find anything that would have been suggestive of a mass that needed removal. They had removed a bunch of adipose tissue, a bunch of fat. And I wasn’t involved in that part. Could I have stopped it in that system? I don’t know. That’s part of the problem that physicians have, right?
Steve Borene: Physicians that are looking for other opportunities will have moments. They used to use the term burnout. Now it’s moral injury, right? And you have things, and that’s something with your social work background, you can understand how that hurts people, right? How you can’t put your finger on it, but it did something to me somewhere and it did it again and then it did it again. And we do that to patients, we do that to caregivers.
Steve Borene: One thing that I always want to encourage for physicians is that there are alternatives where you don’t have to do that. And we need a whole bunch more direct specialty physicians to come on out. I don’t need another thought leader. I don’t want another thought leader. I don’t know what leading the thought is. I want doers, right?
Steve Borene: We want action doers. Where are the people that say, I’m an action leader, right? Well, they’re doing, right? A lot of them aren’t showing up. They’re all over social media and doing things. It’s important, of course, obviously, to get the word out, but they’re the ones that are actually getting dirty hands.
Steve Borene: They’re in that space. And we need more people that’ll do that. We need more men and women in the arena to go ahead and make the difference. And there’s that opportunity to actually make a meaningful difference in people’s entire lives. Physicians used to be business people, and it was an interaction that we had with the healthcare, with the social aspect, and we’ve talked spiritual, with all sorts of different levels, but also the financial. And when you go into any relationship, all those things should be on the table.
Steve Borene: We’ve removed that part thinking that that does something that benefits the patient and the physician, but that’s something that’s really missing in that relationship. If physicians don’t know, because I have that question all the time, hey doc, how much is this going to cost? Well, I don’t know because the system doesn’t know yet. I can’t give you that answer. And the truth with that is when I say that, it means I don’t care. It means it’s too hard for me to try to figure that out, and it may not even be able to be figured out, but I’m not going to put that energy into you.
Steve Borene: And that’s what people hear. And that’s devastating because that affects every other aspect of the relationship. So that when I tell someone, it’s okay, I still took really good care of you even though you’re nauseated. If they know I’m paying attention to all these things and I am bothered and I’m trying to treat that, and that just might be the way they react until the CO2 that’s underneath their diaphragm gets absorbed by their body, they’re going to have that pain. They believe me when I tell them that, when I’ve already built that relationship.
Steve Borene: And that’s something that physicians in the legacy system, they can have a component of that. They can try to carve out part of that, but they can’t have all of that unless they’re having this kind of a relationship. And that’s worthwhile to patients, absolutely, and to caregivers, definitely. It’s an aspect of this job that, the way we’re doing it now, that I didn’t anticipate. I felt like it was missing. I knew there was something missing. I didn’t fully appreciate it until I could fill that.
Andrew Gordon: And I do think too, Steve, a lot of what you’re describing and what I want to give to our audience as well as a North Star, as a framework for anybody who’s working in healthcare, delivering healthcare on the front lines, working behind the scenes to make all these things happen is the framework we talked about in the past, ikigai, and being able to find the intersection of my mission, my passion, my profession, my vocation. How can I find a balance between these elements and those who are operating as you are within and treading and striving within that ikigai framework?
Andrew Gordon: You care, you have to care. It’s your job to care. You feel it. It’s a labor of love. You want to be able to master and learn these different aspects that matter not only to you, but the people ultimately that you’re serving. It’s been an energizing conversation, Steve. Thanks so much for coming on the show.
Steve Borene: Well, thanks, Andrew. It’s always a pleasure. Time with you goes by really quickly. Your questions are always so insightful, get me thinking, and you make it real easy to go ahead and talk about something that I find passionate already. So thank you for that. Appreciate all that you do. And we’ll look forward to continuing to benefit together.
Andrew Gordon: I love it. Sounds good. Thank you so much. And that’s a wrap for this episode of The Price of Healthcare. We’ll see you on the next one. Thanks so much for listening.