Ep. #36 - Maintaining Clinic Culture Amidst Continental Growth: Is It Possible? An Interview with Michael Levy, MD

Deciding to expand your practice, either by acquisition or starting new, is an exciting time. But, adding new staff, physicians, and equity partners can come with a handful of problems. On this episode of Inside Reproductive Health, Griffin Jones, CEO of Fertility Bridge, talks to Dr. Michael Levy, IVF Director and President of Shady Grove Fertility. Shady Grove Fertility is the largest fertility group in America and has over 25 equity partners and almost 1000 employees. Griffin and Dr. Levy discuss the implication of having such a large staff base and just how they manage it, all while keeping the patient at the forefront of their culture.

Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field.

Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.

GRIFFIN JONES: Today, my guest on Inside Reproductive Health is Dr. Michael Levy. Dr. Levy is currently the IVF Director and President of Shady Grove Fertility. He attended medical school at University of Cape Town in South Africa and completed OB/GYN residency and REI fellowship at George Washington University. He has worked to make fertility treatments more affordable for his patients by creating programs such as the shared risk financial program, the fresh shared donor egg program. Dr, Levy also founded the IVF program at Shady Grove Fertility. He co-founded donor egg bank and he's on the scientific and clinical advisory team of California Cryobank. Dr. Levy, Michael, welcome to Inside Reproductive Health.

DR. MICHAEL LEVY: Thank you. I’m pleased to be doing this.

JONES: I'm interested in this conversation mainly because I want to go into the brain of someone who helped found the largest fertility group in America. Maybe I’ll back up and give a little bit of context, because I think what we assume that everybody knows about Shady Grove. There are a lot of people in this country, and other parts of the world, that are listening that are just practicing medicine in their little practice that listen to this show, and they actually probably don't know a lot about you because they don't often check out, necessarily, the other things that are happening with other people in the field--they're doing their thing. You're a group that started in Maryland, in the DC area, you now have close to a thousand employees. Is that right?

LEVY: Correct, yeah.

JONES: And how many REIs are you at now?

LEVY: I’ve started losing count, but I think 58.

JONES: 58, which is just an extraordinary number, considering that a group that had nine or ten would be--most folks would consider a big group and I'm very interested in how that starts. So you're one of many to have found this practice. A lot of people will start their own practice and have 10 people work with them, and that's a good life, and a good career for them. You got a 58 physician group with almost a thousand employees, around 950 when we spoke to Marianne Kreiner earlier in the show. Did you set out to do that?

LEVY: Absolutely not. So my goal for me, career-wise was to--well, first of all, I had a mandate from my wife that I was staying in DR. So I wasn't able to look further afield and there were no jobs available in DC. I wanted to join Frank Chango--and ultimately he became one of the partners in our practice. But my goal when I set out this practice was, if we had three or four physicians and then 3 or 400 cycles, I would have signed on the dotted line right there. So there was no grand roadmap or ambition created at a..

JONES: Well, it wasn't an accident either, because if it were an accident, everybody would have done it. How did it happen?

LEVY: So every quarter I speak to a new hire orientation, and these days that's about 25 or 30 people, which was bigger than our entire staff in 1991 when we started the IVF program. And I'll say the same thing to you that I say to them. We never had grand designs to to be as large as we are. We focus on one core issue and that led to a virtuous cycle, which I think allowed the practice to expand. Before--and you’ll know what that is, but before I articulate it properly--Patty Stull, that you probably know who is the Director of Marketing--not the correct title, by the way, she has a better title than that--but she started at the very beginning with me and about seven or eight years into the practice, when we were about 10 positions and growing rapidly, she was cornered at ASRM by a couple of physicians who said, “Okay Patty, you’ve been at Shady Grove for eight years, what's the secret sauce?” and she said, “You know, the absolute central tenant of the practice is ‘Always do the best thing for the patient.’”And immediately their eyes glazed over they said, “Stop BS-ing us, we want to know the secret sauce.” She said, “No, really!” She says, “Always do the best thing for the patient.” And I think we absolutely adhere to that, and that's allowed us to have patients feel very good and comfortable and refer their friends. For physicians to know that’s the way in which our patients are going to get treated, and what I mean by that is, not only do I need to have very good success rates, we have to be incredibly transparent with patients, we have to have financial programs that are affordable and that in turn, attracts physicians who want to work in that environment, patients and staff who want to work in that environment. We have very low staff turn over. In 28 years, we've had one physicians leave the group and that was because she got divorced and wanted to work part-time and live in Northern California. No other physicians ever left the practice and that, I think, speaks volumes to the environment. And we have a true partnership. We are 100% physician-owned and we have 28 equity partners. And the model is: everyone becomes a true equity partner. Everyone has skin in the game and feels engaged from day one.

JONES: I don't even know how to break this out with 28 equity partners. Maybe I'll come back to that because I'm really interested in how you manage the direction with 28 equity partners. But let's talk a little bit about doing the right thing for the patient. And I can see the physicians’ eyes glazing over as Patty gives them that answer and they’re like, “Alright, tell us, tell us!” What they're looking for one or two tactics, right? They’re looking for something that's a specific process that they used, or some very specific thing as opposed to seeing it as an attitude. And I wonder if that just speaks to--well, there are hundreds of tactics, right? There could be thousands! There are hundreds of different--or dozens of processes. See, there's hundreds of key players. There's however many techniques, but they're all grounded in that one virtue of doing the right thing by the patient. I think we need to explore it a little bit more because, to me, it just seems so subjective. And we were talking about this with--I think I was talking about this on another podcast interview where it's very often like the local restaurant owner that says, “Yeah, we've got the best service in town, but sometimes, they just don't. Sometimes it's a local restaurant that perceives that they've got the best service, and the place across the street does. So as you're growing, that means you've got to measure things. So now you have people in place like Marianne and Patty and some of whom started from the beginning. But, when you're measuring in the beginning, as Michael Levy, someone that starting off with a handful of docs, and now you're at 9 doctors, and you go invest, how are you measuring? How are you keeping the pulse of how you’re serving the patients?

LEVY: On a formal basis, we survey the patients on a regular basis and we get constant feedback. And we’re never satisfied, which is good in your work life, not good in your personal life. So, you know, we’re constantly pushing each other and ourselves and you know any negative feedback freaks us out. So, we look carefully at what the cause was and welcome that. I think most importantly we’ve attracted staff and retained staff who get that. And we were never good at letting anyone go, which was an early problem with Marianne and a more professional HR team. Occasionally, someone doesn't fit in, and we will let them go. But, I think that everyone is a role model for everyone else. So from the front desk, or the new patient call center here, which was a modification we made about seven or eight years ago. Typical doctors offices, yeah, you got someone in the front is checking you in, checking you out, answering the phone, and make a new patient appointment. So when the patient calls up our practice, we now have a call center in our office, very well-trained individuals who know a lot about infertility. We give them a completely different experience with that first phone call. And we look at the whole patient journey and make sure that it's going well. There's some large practices that don't give monitoring appointments--it's like, first come, first serve--you can wait an hour or two for your appointment and we are upset if the patient’s not in and out of the office in 20 minutes for their monitoring visit. We will bend over backwards because everyone knows--we had a patient last week who, with the floods in the Washington area, came in two hours late for her appointment and we had already shut monitoring down. And a relatively new front desk person was talking, saying, “Well, there's no one there, we can't do your monitoring.” And she came to be expecting I was going to say, “Yeah. Yeah, she's out of luck, she's two hours late!” And she's very frustrated, but, you know, and said that she was two hours late, but she showed me a video of the basement flooding. We turned the machines back on, and we got staff, and they did her monitoring visit. And there was no question that that's what we would do. And I'm sure many, many practices would do that, but we are also modeling that for the staff, so that person at the front desk knows that next time, this should be no question that we can accommodate a difficult situation for a patient. So, I think you create a warm--and when people come and visit our practice, almost across the board what I hear is, “What do you put in the water? You know, everyone seems happy! Everyone seems in to it!” We remind our staff that we so lucky to work in this field--unbelievably motivated patients! We transform lives when it works and we have to help them through the difficult journey when it doesn't work. And we need every one of those people to feel the support that we give them. And we do really well about patient satisfaction surveys, but not unbelievably well. And I'm much more anxious about it now, given our size and our geographic diversity than I was with our staff meeting was 15 people in the entire practice.

JONES: I love that you just said that. You’re coming from a practice group that is doing very well just in terms of what the practice is doing. And when you talk about the patient satisfaction survey, “Well, we’re doing well, but we're not doing that great in terms of what I would want us to be doing,” and I think that is pretty telling. I often hear people think, “Oh, we've got the best patient satisfaction,” whether they're looking at any surveys or not. And I often think about a lot of different groups. I just think not hungry enough for me--you're not enough paranoid enough for me that somebody else could be serving the patients better. And I try to run my businesses the same way. With every single thing, “We could be doing that better. This is pretty good. We had a lot of success with this, but I'd still like to be doing this much or have the client this happy instead of this happy.” And I think that's the really important attitude. I also think the example that gave about a woman comes in, she's two hours late, she shows you the video on her phone of her basement flooding, you make the call to turn the machines back on and get her in. That particular example--I think is some version of that, is one that I hear small practices tell a lot about the advantages of a small practice. That large groups don't or can't do. And here you are bringing about that particular example for you. How do you though--is it you, Michael Levy, that can make that call? I mean can an associate doc make a call like that? How do you--when it's your practice, and it is eight people on your staff, it's pretty easy to say, “Okay. This is my bottom line, my top line, I can make a call if I'm going to help somebody out.” Once you’ve got 58 doctors and 950 employees, it's a lot harder to make these judgment calls. So you can make it in your practice, but can other folks and how do you maintain that? If you can?

LEVY: So that's an important point. One of the things that I say to all the new physicians and all the new staff is we want fresh eyes to see situations, and make it better, and empower people. So, I’d be really disappointed if a staff person that had been with us for one week didn’t make that same call. I'm pretty easygoing and I never want to make anyone feel bad about anything, but I would sit someone down, and expect any physician in the practice to sit someone down, and say, you know, accommodate the patient, that's the culture. We had a physician join us, who is a senior partner now, and he’d been in practice elsewhere, and in his first couple of weeks, he had an embryo transfer and there was some communication issue between him and the embryologist, and he was frustrated with it. And he walked into the lab and he started yelling at the embryologist, and everyone, like, looked around and crack that! Like where the hell do you think you are?! You know, that is but what happens at SGF. If there's an issue, you come and discuss it, we’ll explore it, we’ll make sure it doesn't happen again. But that type of hierarchy, that type of bad behavior, just doesn't exist. And what was great for me was, it's organic to the practice of this point. So it's not that we're not a very hierarchical organization at all and everyone who has been here awhile gets a culture and buys into it and reinforces it. So it's not just, I could make that call, or half a dozen physicians who’ve been here for 20 years could make that call, we empower people. The physicians know more about the business realities of this practice within a week of joining us than many physicians do having worked somewhere for ten years. And they've got the you know, seen the partner who is keeping everything close to their chest. So transparency and empowerment are the core of our model.

JONES: That's part of the culture and you say it's organic, but as you start to grow, partly by acquisition--and you talked about that 58 physicians, we had one leave and that time one left for personal reasons--I imagine that doesn't mean doctors of practices that you've acquired, but as you start to acquire practices in other areas, how do you make sure that it fits with that organic culture? Because you've grown it through beginning. You're in the offices in the DC area, you and the founding members now. And once you start to get to other states, you're further away from that base. And you might be hired, you might be buying practices of people that have no problem dog cussing their embryologist in front of the rest of the staff. How do you part ways with them, if that's the case, or get them on board? How do you decide what's the route there?

LEVY: So I think it first goes along with who you partner with. So many of the physicians who have joined us, we've hired, we just know they're good fit and they have the right combination of clinical skills, personal commitment, entrepreneurial instincts, and we want them on the bus. And when we’re looking at a practice to acquire, that is probably the most important issue: will these doctors fit in with the culture? It could be a great business opportunity on paper, but if, on a personal level, you've got a very egotistical physician who is never going to let go, it's a bad start for them and for us. Because you know--but at the same time we don't straitjacket and the personality of our Tampa office, and our Richmond office, and in Philadelphia, will be different to Rockville, but they have enough commonality. So one of the other critical issues we have is we meet on a regular basis. So, three out of four Monday nights, we have physician meetings. We have a clinical meeting, we have the general club, we have the business meeting, everything is discussed. And as I said, it's important, that transparency. So that helps build the culture. And one of the things--we had a very difficult situation a week ago we had to deal with, and the senior partner in Richmond and the senior partner in Atlanta both spoke up in such a moving way to say, “We get the culture, we get how this needs to be handled, and we're fully on board.” And that may not have been the case, and I think it's a combination of we had the right people who we merged with and acquired, and they got the culture and recognize that the greater good is served by all of us reinforcing it. We're not competing with each other, you know, our compensation formulas are very well-balanced and fair, largely rewarding productivity, not seniority, not equity. In fact, the opposite is the case. You have to sell your equity at 65. We did not want to have a top-heavy situation where you've got, you know, a 70 year old physician working part-time and trying to take the lion’s share of the income. You’re phasing out at 65.

JONES: Now, of all the 28 equity-holding physicians, do they all come to those meetings and they all go to the business meeting, via video conference or whatever means?

LEVY: So not only that, but all 58 physicians come to the business meetings.

JONES: Every Monday? Excuse me, every business Monday?

LEVY: So now we’re probably down to two out of four Mondays a month we have a meeting, because it does become unwieldy with 58. So now we have an elected board and no one has tenure on the board. So anyone can get voted off every two years. So we have seven physicians on the board that meets every Monday with our executive team. We have a shareholder group with everyone with equity, which is 28 physicians, and that's a quarterly meeting. And then a business meeting, I think we have one or two a quarter. All physicians, associated physicians, know our revenue, know our profit, know our expenses in detail from day one. We've always held that transparency as a key to the culture/ And it's interesting because new physicians who’ve never been another practice take it for granted. They like it, but they don't know any different. And then physicians who’ve been in other practices are really enthusiastic about having that level of inside and transparency.


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JONES: We had Louis Weckstein--Dr. Lou Weckstein from RSC-Bay Area on the show as well and he talked about how his partners and the physicians at his group meet and they meet each Monday and one Monday a month. They talk about business with 58 physicians, that's a lot harder. So I see the importance of having a group. But, I can't stress the importance of reserving time for all of the partner docs to talk about business. Not just, “Oh, let's pick a time here and we will get to it,” but then so-and-so's on vacation, something happens to so-and-so, and then someone else is covering their patients. And those meetings that are supposed to happen every two weeks, happen every six weeks or every two and a half months and so on. And the time of reserving the attention and focus for everybody to meet and talk about the practices of business, I don't think can be understated. And to me it often seems that the smaller the group, sometimes very often, the less likely that is to happen. One of the things that we do as a company when we start working with someone, is we need to make sure that they have the time, focus, and attention to be a part of whatever engagement that we go through with them, which is why we start off at a very small, little level. People sort of can't get into that little level, they want to do want to jump forward and say “Well, can’t you just put together some service package for us?” And I say, “I'm not going to put together anything that is destined for failure.” And if there isn't the ability of the leadership to say, “Okay, this is important.” Then there isn't the ability of the subordinates underneath them to say, “This is what we need to be working on because we know it's important because leadership is meeting with us on it frequently.” How do you decide who gets on that board? You said it's not tenured. So people can sometimes--people leave. You said at 65, people start to phase out. Is the board sort of a volunteer? We work with some bigger practices that they have at the marketing committee with some of the partners, and you might have a finance committee, and other types of committees, but how do you decide who sits on the board?

LEVY: So it's a mix of our shareholders. So we have an election every two years.

JONES: Which are the 28 physicians.

LEVY: That’s right.

JONES: Now, it's different because your a group that is entirely physician-owned. One of the concerns that a lot of people have is about the consolidation that's happening in our field from groups that are backed by private equity firms. And it would certainly be easier to become the largest fertility group in the country if one had private equity, that things can move really fast, or venture capital for that matter, you haven't yet. So I'm assuming that means that there's some concern, but that's an assumption. Do you share the concerns about what's happening with consolidation? And if so, what are they?

LEVY: So I think that there are many facets to that. I was going to disagree with you that it would happen, you can become the largest group more quickly, if you have private equity. I'd say the opposite is true, because I think you get distracted by quarterly performance, and you have pressures that don't allow you to be as strategic--especially if they are on a short-term exit plan and they try to micromanage without the clinical insight and experienced leader. You know, they may be very well-trained business people, but it's not widgets. And I think that, to a certain degree, private equity is discounted the importance of individual physicians and how much of an impact that has on the practice that they are appropriately motivated. You know, we probably get to calls a week from private equity groups wanting to get into the space and we resisted that. At a certain point, we’re going to have capital needs that we're going to have to address, but we've managed to finance it internally with that and the bank funding. And it is tempting, to be honest, but I think that our structure is such that it precludes all the physicians wanting to exit and get a nice multiple for private equity. Because if you;re 35 years old that a new partner, you’re not as excited about private equity as if you're 60 years old. I happen to be 60 years old, but I like--my primary responsibility is to the practice and to the 35 year old doctors in our group. And I’d be a voter which is good. So I think looking long-term is important for future growth and private equity doesn't look as long-term. We recognize that there are probably four or five networks in the country, most of which are private equity-backed at this point, and they are good competitors. But when I started in practice 28 years ago, a really lovely colleague in the area said to me, “I'm sorry you weren't able to join us because there was no space, but it's a big space with lots of patients, and we’ll all do well.” And that was true then and it's true now. I think the market is underserved. I think we're too expensive. I think that there are patients who don't have access to care who should be accessing care, and we find ways to accommodate them the whole pipe grows and we'll all do well.

JONES: This could be an entirely different topic, but maybe it's worth bringing up--because I really agree that the market is underserved. I talk a lot on the show about the interior of the country, especially because I think we're seeing even more disparity. A lot of younger REIs are moving to the DCs, Bostons, New York, Los Angeles, San Francisco, and very often, the only doctors moving to the smaller markets are those that are from there. They grew up there and they just want to be by their family. Those practices are having a much harder time recruiting folks. And I think that ultimately limits the number of people that they can serve in those areas as well. And this might be a little of a side topic, but did you talk about we're too expensive. I had Rob Kiltz on the show to talk about that particular topic, and I could probably have more guests just to talk about that. Why are we so expensive when so much of what we do is cash pay? The criticism of healthcare and why healthcare’s costs increase while most consumer technology costs goes down, is that it's because you have the government, or insurance whose not really insurance because so much of their liability is mitigated by the government, or someone else inflating the cost--in our field, the majority of it is self-pay at least for IVF. And so why are we still so expensive?

LEVY: You're touching on the topic that I'm very passionate about. I have always looked at ways to ensure better access to care. And if you look at our field, the rate of inflation and IVF is much, much lower than in other fields of medicine. One of the facts I'm most proud of is when started the Shared Risk Program in 1992, our package was $19,000, which included up to six cycles fully-funded to have a baby. We just modified our Shared Risk Program into three tiers and for patients under the age of 35, we reduce the price from $21,000 to $19,000. So 28 years later. it’s the same cost. That's the opposite of what's happened in medicine. And, by the way, as you obviously figure out immediately, we do much better because our success rate is double. As technology improved as it does in other areas, you should become more cost effective. I think the fact that there's such a huge barriers to entry allows practices to charge more, which is problematic. Your costs do go up in general, so our margins are lower now than they were 10 years ago, our pricing has not kept pace. I'm also very frustrated at the cost of medication. I think this is a problem across the board in medicine, that the cost of gonadotropins have more than doubled in the last 20 years. And, certainly, the cost of an IVF cycle has not come close to that. So whereas early on, it was about 20 percent of the cost of an IVF cycle, now could be 50% of the cost of an IVF cycle. Especially when the prices are--I’m going to bash for a little bit here with this opportunity--but especially when you look at Europe, where the cost of gonadotropin is a fraction of what our patients pay here. That's very problematic. So we’ve got a whole health care system that’s messed up. I do believe-- and I'm not I guess it's ironic given my career--but I'm not that much of a capitalist at heart, but I do believe in transparency and price competition. And I think the fact that it's a self-pay market, has kept prices down. If you look at the cost of the knee replacement 28 years ago versus IVF, and you look at it now, it's exponentially higher with the rate of inflation, with the knee replacement. Because patients are looking closely. I could go on and on about this topic and I'd love to talk to you about it again. I became very interested in it. In our practice, our health insurance is our biggest expense after occupancy. And we're now exploring becoming self-insured, because we want to control costs better. And I think medicine has failed dismally at controlling costs. And I do think, if you look at the rate of inflation in infertility, it's much, much lower than medicine as a whole.

JONES: I think we definitely could have you back on about that, but it does explain why you got into some of these other ventures. And I want to talk about how one gets in them, because I think a lot of--especially principals of fertility groups--have the opportunity to maybe be a co-founder of a new software, a new EMR, a new, maybe an opportunity to get involved in physician-owned pharmacies, or a number of different side ventures, sit on an advisory board for some large tech start-up or existing pharma company. One of the things you started with, this passion you talk about, why you started the shared risk financial program. Then you also helped co-found Donor Egg Bank and I think you're involved with my friends at EngagedMD. How do you make those decisions? You've got your main focus, which is presumably the practice group, and then there are different ventures and there could be a thousand that feel meets technology and meets all of these new opportunities. How do you decide which ones are a good fit? What advice would you give for principals that are thinking about maybe getting involved in some sort of venture that is ancillary to their practice?

LEVY: I think we always do better in an area that we know well. For me to say, I think I’m going to invent some kind of IT opportunity unrelated to fertility would be completely crazy and that would be almost certain to fail. But, I think if we have entrepreneurial instincts and we see areas within our field that open up new opportunities--I think egg bank exemplifies that--and we pursue it with a vigorous focus, it will be successful. So, when the new technology for egg freezing was developed about 10 years ago, I think that it opened up a big opportunity with egg donation. When typically one egg donor was matched with one recipient and it was extremely expensive, so egg banking allowed went to decrease the cost by less than half of what it used to be. And we were early adopters of it and started the egg bank in partnership with a number of other groups.

JONES: Maybe a good place to conclude is with the model that you talk about. Because you made a really great point, which is when you're 35, a private equity offer isn’t so exciting. When you're 60, the private equity offer is a lot more exciting, because the buy-out is essentially one’s golden parachute for retirement. And I have made this argument on the show very often that I think no small part of the reason and why a lot of retiring physicians, or doctors that are within five years of retirement, are taking this exit because they don't have another exit! Because they don't have a doctor that wants to take over their practice, or if they do, there's trapped equity that the incoming doctor can’t afford what the practices were, and even if they can, the expectations aren't set well. We talked about that with Holly Hutchinson on the show of why associate doctors would leave after two or three years before ever becoming a partner and why that happens fairly--pretty quickly. So, I think maybe the 5-7 doctor groups, because they're still a decent number of those and they haven't sold equity yet, but they're probably around that age where they're really thinking about it. Does the Shady Grove model work for someone that size where you're getting people in, they’re meant to be on partnership track, and then the older doctor meant to phase out. Or is it too late if the doctors are at a certain age or a certain career?

LEVY: Yeah, so we we refer to our constitution as critical components of our practice and that's all embedded in our constitution and I don't think it's too late for any practice. I think that you’re absolutely correct that if an earning avenue for exit in significant way is private equity, and you don't have younger physicians who are going to purchase your equity in the practice, you're in trouble. So we have a very clearly defined internal multiple and exit. We’ve had three physicians or more probably this point. So when I started the IVF program, I joined Arthur Segoskin and Bob Stillman, who had been our fellowship director at GW, joined us five years later. Both Art and Bob have now sold their equity in the practice and that was very orderly. The younger physicians hold the equity. It's a win-win. They got a good valuation and the younger physicians got a good deal to be able to acquire that equity. So I think ensuring that that is in place at the earliest stage is a good idea.

JONES: Can doctors do that like an owner-financed home? I buy the home from the older couple who's going into the nursing home, we don't get the banks involved, we draft the contract and maybe I put down a down payment. I owe them directly, as though I am paying them the mortgage, not the bank. Can it happen that way? Or do younger physicians typically have to get loans in order to be able to buy that?

LEVY: So the way we structure that when physicians buy into the practice is we--the practice guarantees a bank loan for them. So it's a significant amount, but the return on that--and they earn that equity they want--and the return of the profit pool that is returned, according to equity more than pays it off for them right away. So we ensure that they will do better from there as an equity partner. Everyone can get about the same amount of equity in the practice, but someone has less productivity would not be able to afford to buy the next little amount of equity that they could, because it would be too expensive. But I think it could be financed internally by the practice. I don't think that you have to involve a bank to do it effectively. But I really do think that it's--when we interview, it's interesting, I think the incorrect stereotype applied to millennial physicians, or graduating fellowship, is they want to check in and out, they want to get a nice salary, they aren’t interested in the business side, and they aren’t that focused on the long-term partnership track. I think many of those probably exist and those are the ones we’ll attract. Most of the physicians that come to us from word-of-mouth, know that they are going to have the opportunity to become true partners. It is important to them. They have to be productive and fit in with the culture in order to achieve that opportunity. But I think we have--in an era in which there are fewer of them graduating then there are positions, so the most fellows get multiple offers--we have almost our pick of the fellowship graduates who are not getting into research, the one getting in clinical practice, because of that model.

JONES: I think that, that point of, there are still so many entrepreneurial REIs coming out of fellowship, so many of the--some of the millennial REIs that I know, some of whom are still in fellowship, are among the most entrepreneurial that I know with their involvement and looking at Silicon Valley, they're following funds on Wall Street. They are really dialed in and I think from a recruiting standpoint, why it sometimes appears that way is because these millennial physicians are going toShady Grove, often times are not going to another place because you have a structure for them. A lot of times, there isn't a structure in place and the ambiguity that sufficed 25 years ago, doesn't suffice anymore. They need to go to a place that has a human resources department, that's active on social media, that isn't using paper charts, that is forward-thinking, because--I make the analogy very often that it's like buying the old house, but the work needed on the house is so much more than just then buy-in. And especially if there's going to be someone in place that’s quieting you on the changes that you need to make before they retire--if they ever retire. And I think that you all have that structure in place, it seems. So I'll give you the final thought! What would you want to conclude on? I did I like that you countered my point that it would be easier to use private equity to build the largest practice group in the country. You countered because you've actually done it, so it happens true. He said that you didn't set out to do that, but for someone who wants to grow or sustain their practice, or your general view of the field, how would you want to end?

LEVY: You know what one area that you have a question that we didn't touch on which I'll finish with is, I think one of the other really key decisions we made early on is that physicians need to fully engaged, but they should not be the business leader of the practice. So we have a really superb executive team led by Mark Segal, our CEO. I think Mark had the vision and mission to grow as big as we did. And we went along with him in support of that. So, we have the right balance between not trying to micromanage. I do see physicians fall into the trap of, “We know a lot about a little, so we assume we can learn a lot about everything,” and you know, that's risky. So we have, as you said, great HR, great marketing, administration, accounting, and we don't micromanage that group at all. The board meets every week with that team, so we know what's going on. And we’re involved in important decisions, but finding that right balance is critical for the right foundation for the practice. I spent 80% of my time practicing typical medicine. I still enjoy it the most, which is why I keep doing what I'm doing. I certainly want to be involved as do all our physicians. And lastly, I love the fact that you say that you're familiar with a lot of entrepreneurial young fellows and reproductive endocrinologists and send them our way! But I wouldn't want that to be their primary driver. The right physician in our practice is going to do what's right for the patient every time. My favorite patients are those with sexual dysfunction where I send them home with a ten-cent, 5cc syringe and tell them to inseminate themselves at home and they don't need us for anything and we make--because we’re doing right by them. It’s the most cost-effective treatment. And if everyone knows that that's what we're going to do, the practice is stronger for it, because they're going to send their friends, they’re spouse will know that's what's required, and they get to act like that in every situation. And of course, I love the patient with the complicated situation and they need to use all the bells and whistles of technique. Bells and whistles of the top technology get a good result, but we've got to tailor to the patient. So do right by the patient, but be entrepreneurial and a successful father.

JONES: Dr. Michael Levy. thank you very much for coming on Inside Reproductive Health.

LEVY: You’re very welcome and I enjoyed it!

You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.