INSIDE REPRODUCTIVE HEALTH PODCAST
Ep. #41 Are Young REIs Entrepreneurial? One REI Fellow’s Vision for the Field, Eduardo Hariton, MD, MBA
The business of medicine is complicated and more often than not, the concept is split and managed by two people with different backgrounds and education. But what if they merged? On this episode of Inside Reproductive Health, Griffin talks to Dr. Eduardo Hariton, a clinical fellow at the University of California in San Francisco. While attending Harvard Medical School, Dr. Hariton also attended Harvard Business School, simultaneously earning his MBA. Griffin and Dr. Hariton discuss the merging of business and medicine and how new REIs can gain business skills while still focusing on what is important: the patient.
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 fertilitybridge.com 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, on Inside Reproductive Health, I am very pleased to introduce you to Dr. Eduardo Hariton who had received his undergraduate degree at University of Florida, went to Harvard for a combined Medical Degree and Masters in Business Association at Harvard Medical School and Harvard Business School. He stayed in Harvard for his residency in Obstetrics and Gynecology, which he completed at Brigham and Women's Hospital at Massachusetts General Hospital in Boston. He is currently a clinical fellow in Reproductive Endocrinology and Infertility at the University of California in San Francisco. Dr. Hariton, Eduardo, welcome to Inside Reproductive Health.
EDUARDO HARITON: Thanks for having me, Griffin.
JONES: I only read half of your bio because the reason why you are on this show today, is that I have heard so many times, more times than I can count in the last few years, that people in fellowship right now, coming out of fellowship, younger REIs, are not entrepreneurial. And I want to introduce you to the field because I think you, among some others, but you just sit as sort of a good snapshot of this new profile of REIs that are very much entrepreneurial and it looks a little bit different. And I think the fact that you would get your MBA from Harvard Business while you were becoming an MD at Harvard Medical, it showcases that. So let's start with why that was important to you to do. Why would you want to do something as intensive as get an MBA from Harvard while you’re becoming a doctor?
HARITON: Well, you know it's kind of an interesting story because I did not go into it thinking I wanted to get an MBA, initially. I was always interested in Public Health. I was interested in access and taking care of underserved populations. I worked in homeless clinics, I worked in shelters, and I realized doing that, you know, the problems that we were facing there weren’t problems of public health or problems of epidemiology, they were problems of business. Most of my mentors were PHDs or NPHs that were working in those fields. But what we truly struggled with was how to use resources effectively. How to redesign flow. How to make decisions that will allow us to take care of more people in a better way. And when I got to Harvard and I was trying to decide between going the NPH right and getting a Master's in Public Health or getting an MBA, I realized that the MBA would not only provide me with some of those hard skills of business, marketing, finance, accounting, but they would have also pushed me outside my comfort zone a lot more. In public health, people think like physicians, we believe that healthcare is a human right, and in the business school, most of those assumptions are going to be challenged. You're going to be seeing people who sit on the other side of the political spectrum from you, or the socio-economic spectrum for you, and you're going to be challenged to defend your positions and you’re going to learn from others. So I felt like it would be an experience that we provide me a lot more growth and it certainly did. I did gain a lot of hard skills that I apply in my day-to-day, but I think most importantly, I learned to think outside the box. I've learned to come at a problem from different angles, partly because I was in that setting where I was challenged, but also because we go through five hundred different cases from different companies and different industries and you start to see a pattern of how people who push the envelope and do things outside the box are able to create meaningful change. So I felt like even though I didn't go to the straight route when you know wanted to do it since I was a kid, it was an experience that definitely provided a lot of growth for me and skills that are used to this day.
JONES: Of each track, of the medical track and of the business track, are there examples that you can think of that you felt exposed what was lacking in the other? For example, “Wow, we should really be learning this as MDs,” or “Wow, MBAs or business students should really be studying that.” Can you think of any examples of the top of your head where one covered something that was left exposed or untouched by the other?
HARITON: Yes, I think in business school, you certainly cover a lot of hard skills that you don't in medical school. I think that going through a medical degree, we do not get a lot of training in formal leadership. We do not get turning on the business of medicine. We do not get training on how to run a clinical operation efficiently. And in business school, you really do tackle those issues very decisively. And that is something that is improving. I think they are starting to pay more attention in the medical field that that's something that needs to happen, but we're certainly not there yet. And I think on the other hand, in business school, we often like things in numbers and be quantitating and I think that the fact that it sometimes makes is that you can't put everything numbers, right? Like when our patients suffer, when someone has a bad experience, it's not just, oh, it’s going to affect our Net Promoter Score or our clinic might not see that patient back. Someone is suffering and it's hard when you're sitting in an ivory tower far away from patient care to really understand what that's like. So I like where I'm sitting, where I get to sit across the desk from patients and talk to them about the issues and I think that informs the decisions that I hope to make as a manager. Because if you are on the ground and you are seeing patients and they're asking you tough questions, you are going to have a lot of insight that then you can go and translate into your practice strategy. And I think that when you silo those two functions, and there’s no--it doesn't have to be the same person--but there has to be those functions in order to make sure that as you're moving your practice strategy forward, if your medical director is driving change, keeping in mind that you're doing so for your patient. And you are being guided by what they need, not by what you think they need, is the bottom line.
JONES: How much of what you learned in business school do you feel, if any, should be requisite in medical school, residency or fellowship? A common complaint I hear from fellows, people coming out of fellowship, is they get very little business training other than Park City, there's not really anything built into the training or very little in medical school, if anything. And most people I don't think can replicate what you did do both tracks at the same time. Maybe I’m making that assumption, maybe that is something you argue for, but what do you think should be requisite in medical school, residency, or fellowship training? From a business perspective.
HARITON: I don’t think that an MBA should be requisite by any means because I think that my interest and the fact that I wanted to pursue it is not something that everybody wants or is interested in. I think that we are doing a disservice to medical students by not exposing them more to the business of medicine because it doesn't matter what field you're in, whether it's REI, OB/GYN, Internal Medicine, Pediatrics, Plastic Surgery, you are going to be facing some sort of cost pressure. You are going to be dealing with billing and you need to understand how our healthcare system works. I think physicians, by nature, do not want to be taking business decisions, but the decisions are going to be made for us. So I think that involving the next generation of physicians in understanding what are the problems that we're facing and engaging them in thinking creatively about how to do so, because they are the people in the front line. It's really important and it doesn't take an MBA to do that. You do not need to know how to understand a balance sheet to be able to understand what are the challenges of collecting your invoices and billing, or how to negotiate with the insurers. You don't need to negotiate with them. But you do need to understand that there is a process and that's how when you get paid gets paid. So exposing people in short bursts, from medical school through residency and getting them more specialized after they pick their field. I think that will be helpful for everybody and we create physicians that are more prepared to engage when they are in practice.
JONES: Why do you suppose that this has not already been manifested in training, or residency, or medical school up to this point? Because this complaint has been around for a long time--that physicians don't get business training. And sometimes unfairly, but sometimes very poignantly, one thing that’s very common to say on the business side of virtually any discipline in healthcare all the way to the dentistry and chiropractic, is that doctors are not business people. They very often want to be employees of their own practice. And sometimes I think that's unfair and sometimes I think it's perfectly fair, but certainly the complaint has been around for a long time that business training has not been required, or even available, to most doctors. Why do you suppose that is?
HARITON: There's no time, to be honest with you. When you look at the length of residencies and what we're teaching people, knowledge is growing exponentially. And everyone who has taken step one knows that it feels like you're drinking from a fire hose. You're trying to absorb as much knowledge as possible. Your time is certainly not growing. The amount of material that you need to learn both in medical school and once you get into practice is growing, and when you have to make a trade-off between taking someone finance or accounting, or teaching them updated medicine that they need to safely take care of patients, medicine is always going to win. So I think it's a matter of time and priorities, and I think to a certain degree that our priorities are very correct. We do need to train our clinicians in taking care of patients first. I think that when we think about how we can do this more efficiently, I think there's a balance--and it doesn't require a lot of time to introduce some of these important concepts. And like you said, some physicians don’t want to be in business and I think people self-select the people who do want to be on the administrative side are going to go and pursue either extra degrees or other training or when are just going to read more or engage with those people. And the ones that want to practice and make the salary and take care of patients are going to do that as well. But by finding that balance and teaching the basics, I think all physicians are going to be better prepared and I think down the line, better physicians because they're gonna be able to take care of patients with a much deeper understanding of how the system works.
JONES: I disagree that many people are our self-selecting, at least skillfully. And there's a lot of people that own practices which are, by definition, for-profit entities, but still prefer as you mentioned, they want to see their patients and that's it. But they are competing with entities that very much know that they are for-profit entities. So I think the self-selection has been poor, if it's been made. We can talk more about that, but I want to wax philosophical on the point that you made about priorities because I think you're spot on that medicine has to win. That's why people are medical doctors and there isn't more time in the day. Does that naturally make a case for why there is so much private equity and business executive structure in the new networks that have formed. Does that make justification for structures like those because MDs need to fill their time with advancing the latest in treatment in medicine and and there is no time left for business, so somebody else should be handling that?
HARITON: Yeah, I think there's a lot of money coming into the fertility industry because there's a lot of promise and a lot of growth in the fertility industry. There is something to be said, you get consolidation of practices and larger enterprises that are diversified across different cities and different geographies. You are going to need to develop a corporate structure to be able to maintain culture, achieve efficiencies of scale, and that will happen and, to a certain degree, that is something that private equity knows quite well. I don't know that necessarily. Physicians have to learn the medicine--I think physicians often want to focus on medicine, then they decide to know the business side.I think sometimes it's just an evolution of growth. I do think that it's important to engage with those companies and try to help preserve what matters to patients because we are the ones that know that. But at the same time, there are a lot of really good practices that come with smart money that are helpful in helping us care of patients better. There is some capital that can come in helping you improve your EMR system, improve your call center, and that can actually be good for patients. So I think by engaging with those groups and saying, you know, how can we make the patient experience better? And having the patient as the center and your ultimate goal, you’ll be able to combine both what's good about physicians and what's good about non-physicians into an organization that can do really well, and, I think, can change the way we practice medicine.
JONES: Let's stay on priorities for a little bit because I think there's so much to unpack. And I believe that every business owner, not does physicians or practice owner, every business owner is ultimately responsible for the future value of his or her business. And the reason why so many businesses fail over time or fail to adapt to change is because future value has not been considered or brought down to the operational level frequently enough to where they can adapt over time because the other priorities take place and that the role of an executive in considering future value, possibly priority number one, isn't even deciding what needs to be adapted into the fold, but what needs to be cut. To your point about that there is no more time, we can't really add any more hours on to the week, especially for residents and medical students who have their schedules packed already. There is not really any more time and there's likely not any more bandwidth either. In business at the very least, we need to decide what needs to be cut. I cut something from my business every single year, so that I have the time to focus on something else. Is there anything that can be cut in fellowship, residency, in medical school that you feel is less important, less relevant that should be replaced by something else--and by something else, not something that's just not medicine and treatment?
HARITON: You know, that’s a tough question. I don't know that you can kind of point your finger on one thing that can be cut. I think that we can certainly make training more efficient. We have people going through OB/GYN residency during their fellowship, and do hundreds and hundreds of deliveries and c-sections, when I'm now going to focus and infertility. Same thing with oncology. You know, maternal fetal medicine doctors do a lot of laparoscopic surgery, and then they don’t do it again. So there's something to be said about preserving the generalies that can do it all, but there are also some ways to think creatively about what are some avenues to make sure that we can get people who want to specialize to their specialty sooner. And we preserve that case to generally some people who are going to do that often in their life. That takes a lot of vision. It takes a lot of power from larger institutions like the American Board of OB/GYN and ACGME, so it's not something that I see coming in this short horizon, but I have written about it. And I think it's important to think creatively about how to do that in the long term because I think that's what's going to keep our physicians engaged and that was gonna get them out to practice to take care of patients sooner. You always have to do it in a safe way and you always have to make sure that everybody is trained appropriately, but I think we can do better in designing systems that can do it more effectively.
JONES: And speaking of engaged, we've really just been talking about business at a conceptual operations level, we haven't even talked about things like personal brand, or dissemination of information, or promotion. And you I've seen a lot more of on Instagram, and I’ve had the conversation on the show a few times that most of the most popular REIs on Instagram are women. In fact, just by engagement, they all are if we’re looking at the six or so that are most popular. If there's somebody that's going to make me change that statement in the next months or years, I believe it's you because--. I really want to commend you on just how active you are on Instagram, but how you're able to disseminate the information and you take the time to write it in both English and Spanish. So we're really talking about quadrilingual here, because we’re talking about English, Spanish, image, and in the text, you’re using the emojis--which I very much feel is the current currency of language. So just talk about why you feel that that's important to do?
HAIRTON: You know, it started very kind of organically by talking to a lot of friends. I would have probably a 30 minute call with some friends that was either trying to get pregnant or pregnant about to deliver and going through similar information, trying to engage them in the same way that I did with patients and educate them, and I realized that a lot of people do not know where to go for information and what to trust. Physicians like to believe that they're very accessible, but when there’s a month or two wait time and a 15-minute visit, they truly can’t get all the information that they need. I felt like I was in a position to be able to do that. I really strongly feel that doing it in Spanish allows my Latinos and Latinas to understand what's happening in a much more personal way that is more natural. So it's something that’s really important to me. And I feel like I haven't been doing it for that long, but I have definitely gotten very positive feedback that people find it helpful, hat some questions that they and their friends have been thinking about have been answered by some of my posts. And the ability to think that with one or two hours of my time creating a post and working at it, and it does take up my time, but I am able to educate a hundred, two hundred, five hundred, a thousand women at the same time and make their experience better, there’s something really powerful about that. So I’m really enjoying it. It is a lot of work, but I think, at least for the near future, if time allows, then I’m certainly going to continue.
JONES: You're also helping my Spanish! I read it and there are examples that I see--Oh, I wouldn't have known to say it that way.
HARITON: Well, actually I think that maybe like four or five REIs have messaged me and said I’m definitely working on my medical Spanish by reading your posts! So, I’m glad that it helps.
JONES: It is helpful!
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JONES: Let's go back to the start where I introduce to the contention that I hear sometimes REIs aren’t very entrepreneurial, but I'll bring you on as an example of who I see as the new profile of the entrepreneurial REI. I wrote about this in 2018 and I talked it up about it on probably every other podcast episode because when I hear some physicians say this new class is less entrepreneurial, they don't want to take over practice, they want to punch the clock and go home. What I see is just a different set of risks that I believe younger REIs are also analyzing. So what I believe is that that generation is getting ready to retire now, the ones that opened their independent practices after leaving universities in the mid-90s, they inherited a practice model that is a general practitioners medical practice model from the mid-twentieth century or earlier and is not a model that is adapted to 2020 or the business climate of the 2020s. And I believe that younger REI simply recognize that and that they don't want to inherit the depreciating--what they perceive as the depreciating value, or the higher risk, or what requires a lot more capital investment, or adaptation with technology, that’s just not that good of a deal to them. And I don't blame them. So before I go to where I see your profile, I just wanted to see if you agree or disagree with that assessment?
HARITON: A little bit of both. I think that certainly there is a lot more hesitation from young physicians coming out of practice to either start new enterprises or not buying them right away. I think part of that is the multiples, or the value of practices, have gone up significantly because there's a lot of other people with a lot of money trying to buy them. So when other REIs are trying to exit and they’re bringing new physicians, they also have an opportunity to sell to a private equity or other larger groups that might be able to afford more. And that practice--because it will be part of a larger network--is worth more to that company that has 20 practices already and is starting to enter a new geography--that is worth to an incoming REIs that has to build up volume, that still has a lot of loans to pay, that have gone through 15 years of training, and they get pretty low wages for their education level. So the equation is tough for a new REI going out into practice.It's still being done--it’s done in the East Coast, it’s done in the West Coast, it’s done in the middle of the country as well, but it is a little bit of a harder equation and you have to really make the numbers work for you or really believe that you are coming in and have some sort of differentiation. Luckily for us, we're seeing so much growth that hopefully a lot of these new entrants will succeed along with the big conglomerates of practice. But I think that's what's driving the hesitation that a lot of people feel that coming out.
JONES: I wonder though what happens to equity if people can't build it. So, we had Michael Levy on the show and Shady Grove has a really interesting model. And there are other groups that are offering either partnership or really high salaries that are attractive to people, but doesn't the multiple really come from when you build the equity yourself? In other words, if you become a partner of a very, very large group, I see the track there, but when some of these groups are selling for multiples of five, six, and I’ve heard the stories as much as everyone else has of some of the really lucrative groups are selling at multiples like 10 to 12 times EBITDA. Doesn't the multiple come from when you build the equity yourself? Is there a missed opportunity for younger REIs if they're not building the equity themselves? If they're just getting in on a larger group from the beginning?
HARITON: I think that when you look at it from the purely financial standpoint, a lot of the REIs there are two big exits. It comes from growing the practice yourself, like you said, it comes from starting from little, growing your patient base, getting a good foothold in your geography, and doing pretty well, and that is called sweat equity. You don’t earn it just because you invest money and it’s going to provide a lot of return. Those people really busted their butts for many many years growing their practice and they are seeing the fruits of that labor. I think that when young REIs are trying to make the decision of whether to go out with a big group or a smaller group is very personal and it depends where you want to practice. You know, you will have a much larger share of the pie if you're in a smaller practice, but you will also have a share of the pie in the larger practice. And when you have 20 centers across the country, you have a lot of economies of scale that you can use. You can have your marketing functions work across all of them, your billing functions work across all of them. And when we think of a lot of insurance coming in, larger groups are probably going to be able to negotiate much better insurance rates for patients that do have coverage then a single practice or a couple of centers practice. So that is also going to make a difference and I think that the choice is quite personal. I think that for some REIs, a larger practice makes sense. For people who are just want to run their own show and build it from the ground and they're willing to put in the work and they do think it's a lot more work depending on your setting, maybe a smaller one makes sense. But at the end of the day, I think people will go where they need to go and if they went to the wrong place at first, then they’ll pivot and change jobs and that is okay as well.
JONES: Have you made your decisions already in it? That would almost sound silly a few years ago to ask someone who just started their first year of fellowship, but I don't think it is silly anymore based on how I see recruitment of new doctors coming. Have you made a decision, not which particular group or entity might go with, but which class?
HARITON: Not really, to be honest with you. I think--I’m in my first few months of fellowship and I'm honestly just enjoying learning about infertility, getting to know the patients, and truly delving in this field that I've worked so hard to get into. So I kind of have my head down trying to learn the medicine because like I said, I think that is the most important first step in becoming an infertility physician. I think that what I do know is that I know the things that are important to me: I want to work with people who are really to challenge their assumptions in order to take better care of patients. And that can happen in a small practice or a big practice, it happens in some academic practice, some private practice. So the setting doesn't matter as much as the culture. And I want to work with people who are willing to change and redesign themselves and whether I find that in one setting or the other setting, I don't know yet, but I'm going to work and learn how to take the best care of patients possible, and then finding a group whose values align with mine.
JONES: Have you thought about where that might be? You’re in the Bay Area now, you’ve spent a lot of time in Boston. You’re married and I believe you have one young child?
HARITON: Yeah. Yeah, a six month old girl.
JONES: I just heard the “Aw!” come from the audience! Have you thought about where that might land you? So you're open to what type of practice or institution, provided that they are not only amenable to change, but who wants to have their assumptions changed, and is open to more radical transformation, but have you thought about where you want? Do you know you want to be in a big city? Do you know you want to be in like a liberal state? Do you know that you want to be in a certain kind of are? Do you want to be in the Bay? Have you thought about any of that?
HARITON: Well, we have family in the Bay. My in-laws are here, my parents are in Florida, so being close to family is important. And I think that, usually on the medical cycle, every four years, my wife and I get together and we make a joint decision. She’s a professional, she has her own career and we try to figure out what is the city where we both can grow and progress. If SF is working out great because her parents are here, because she's in marketing and there's a lot of consumer marketing jobs here that she can engage with, so I think that--I don't know that were restricted to a specific location. We're really enjoying our time here so far, and we're here for two and a half years, but I think that it's important to never get too comfortable and always figure out as a couple, as a family, where's the right place to be for us and when make a joint decision together that you're both happy with, both personally and professionally.
JONES: Well, let's test how far this could go. I know there's no REI practices in Steubenville, Ohio. Let's pretend that there was and let's pretend it fits perfectly with the culture you want of being open to transformative change and has a fantastic practice cultures on the cutting edge. It's totally in line with your values, but it's in Steubenville, Ohio. Do you move to Steubenville Ohio?
HARITON: I think I might! I see your point and I’ve heard your podcast where you discuss that you feel like people are going to big cities and not going to the coast. So I can see where you're coming from. I think that if you found a smaller town life was what makes sense for you, it is definitely a great place to live. There are a lot of small towns all over America that need infertility physicians to go take care of them, where you can have a very comfortable living, your kids can go to great schools and you can really build a practice that takes care of a large population of patients. And you know, it is hard to move to a new town where you don't know anyone, which is why I think a lot of people end up staying in larger cities or going back home and that can certainly be a challenge. I would not be opposed to it. I have moved from Venezuela to many cities where I knew no one and have made great friends and started a family. So I am not opposed to the challenge, but like I said happy wife, happy life and you have to make decisions together for your family!
JONES: Smart man! And so for everybody listening is there's a free agent on the market still early in his career, but it sounded pretty open. But I like to pretend that you're starting price just went up a little bit because of this podcast. That’s my pious hope!
HARITON: I appreciate it!
JONES: Let’s talk a little bit about the profile that you see for this new entrepreneurial class of REIs and some of the opportunities. Because to me it just seems like there's so many opportunities--and I'm not talking about like which practice group you go to, I mean opportunities beyond that. If you were an REI in the mid-90s, there was probably a few pharma companies whose board you could sit on and you would have that side gig that way. With all of these companies coming from Silicon Valley and Wall Street, and there are only going to be more and more, every single one of them needs a medical director. There are so many opportunities for younger REIs. What are some of the ones that you see?
HARITON: I think that the traditional one is going out to practice--joining an academic practice or a private practice, a lot of people can do that plus being a medical advisor or engaging as a medical director as some people have done. You could go out of medicine completely and then work with one of these companies here, either seeing patients or not seeing patients, and those are all viable paths. I would hope that most people who come into REI do so with the desire of being engaged directly with patients at some point because I do see a severe supply-side program that is coming down the pipeline. I think that the growth that we're seeing in our patient volume is exponentially higher than what we're seeing in our physician workforce, which is honestly mostly stable. So I hope that most people do stay and take care of patients in some degree or another, but I find that it is important to engage with all of the companies that are trying to enter infertility. I think that as physicians, we have a unique perspective. I think often our got reaction is to say, “Oh, they’re doing it wrong” or “They’re in it for the money” and a lot of times they are, but they're also trying to help patients in their own unique way. They are bringing expertise that we have physicians don't have and they are seeing the place where they're able to engage with a lot of patients. And in a short amount of time, collecting a lot of data that is helpful to answer some of the questions that we try to answer in research. So I think that rather than say this company doesn’t know what they're doing or they're not doing it the right way or they're marketing in a non-transparent fashion, I think we should say, “Hey, I see what you're trying to do. Can we talk? How can we work together to make sure that we help you achieve your mission which ultimately will help patients? But we also help guide you because we have 10, 20, 30, 40 years of experience in the field and we know how its evolving and what patients actually want because we sit across the desk from them.”
JONES: Maybe I jumped ahead in talking about assumptions--or jumped over the part where you mentioned assumptions--are there particular assumptions or patterns in the delivery of fertility care now that you see should be challenged?
HARITON: I think one of the things that patients often look for are success rates, but I think that they also look for convenience. They want to be able to answer, access their provider quickly, they want to have information in real time. Most of our patients are millennials, they work on their phone, and they want to engage with their providers, often faster than we are designed to do. So, I believe that having good success rates will only get you so far. I think that people need to work on the customer experience and need to understand, what is the patient really seeking? Have a website that has information, have a line that is able to provide answers quickly, have an app that is able to give you the medication dosing faster so that they shouldn't feel more engaged. And I think that's going to help drive value for customers and I think companies or practices that are willing to invest in that infrastructure early, are going to see benefits down the line.
JONES: To me, this seems like such a natural relationship between that medical advisor role, or between that medical director role of other companies. How else you feel that younger physicians will play a role in Wall Street or Silicon Valley? Meaning, being investors, helping direct this? How do you see the relationship between this generation that you're coming up with of REI physicians and--let’s call it--private equity and venture capital?
HARITON: I think first we need to pay our loans and then we’ll worry about investing. But I do think that we're growing up in a different fertility field. That's why I came in. I love change and love technology, I love working in a space that is constantly evolving and I'm gonna enter field in the couple years that is very different than the field that people ten years ago entered in. And a completely different planet that the people entered 40 years ago. And I think that that's exciting! We will have patients that will come after testing their own AMH at home and ask us to interpret it for them. We will have patients who froze their eggs at 25 and are ready to have families and we will have to basically face those patients and help them interpret the data. We will also have patients that want to do IVF for genetic reasons, which is not something that was done in the past. So I think that the new REIs are dealing with a much more crowded field, but also a much more exciting field. And we have an opportunity to help guide patients through it, and then also partner with some of the companies that are helping revolutionize the field to make it better for patients, whether they are 25 year olds that are not thinking about starting families yet, or they’re in their early 40s and need help building their families.
JONES: I know that you're generally not one for active investing, but I also know you pay attention to the IVF segment of the market. Who and what should we be paying attention to there?
HARITON: I don't know that I like to speak about specific investments because then they all become dated. I think that it's better to focus on what are the trends that are driving growth in this field and that are going to make our whole industry appealing. I think I already touched on growth and I think that infertility growth means that the number of cycles is going to double about every seven to eight years. If you assume 10% growth, which we are seeing more than that, in eight years we are going to have double the number of cycles. And when you put it like that, it really shocks people because we're not really the size to accommodate that demand. We're going to see more insurance coverage coming in. A lot more patients are going to have plans that are going to contract with clinics and I think that’s going to drive reimbursement per cycle down. So our margins are going to shrink, but our volumes will go up. I think that's good for patients. I want to take care of patients that previously couldn't afford to do the IVF care. And we're going to have to think creatively about how do we make sure that we can run sustainable businesses that take care of a lot more people when we getting paid a little bit less per patient on average. I think we’re going to see a lot of IVF for non-infertility reasons, like I mentioned, a lot of people who do carrier screaming and have recessive conditions, that they have a high risk of passing on to her children are going to come to us and are going to ask for help making sure that that doesn't happen. I was looking at this a couple months ago and it costs about a million dollars to take care of patients with sickle cell from birth until they're 45 years old, give or take. There's a one in four chance of passing that condition if both parents are carriers. So, you know, and I'm not thinking of the suffering which should be reason enough to take care of these people and help them not pass it on to your children. But if you just wanted to look at it from a cost-effectiveness standpoint, if you spend less than $250,000 in doing PGT-M, and getting rid of that condition so that the child is not affected, it is cost-effective. So, I think that that's a very simple and quantifiable example, but I think we're going to start seeing more and more people coming to REIs asking for help making sure that they don't pass genetic conditions to their children. And we're going to understand more about genetics and being able to help with that. So yeah, I mean those trends, I think, will help drive a lot of change in this field and they will also help drive a lot of growth that at some point we're going to have to deal with creatively.
JONES: Have you read Hacking Darwin by Jaime Metzl?
HARITON: I don't think so.
JONES: I just had him on the podcast, I don’t think if his episode will air before or yours. But dealing with a lot of equations that you talk about, you gave one example, another example is cystic fibrosis and that might be $600,000 for a lifetime of caring for someone. And talking about how assisted reproductive technology is moving far beyond those coming from infertility as a diagnosis, but those that have genetic concerns or genetic disease, to far even beyond that in the future. And so that expansion just blows my mind. So your need for efficiencies--there's the meat that you pointed out for efficiencies and finding a way to deliver twice the volume then were delivering today as early as eight years from now, I think is very urgent. Eduardo, I really mean it when I have you on this show and I say that you're a rising star of field. For anyone that thinks, oh he’s in his first year, how can you say somebody is a rising star? I'm just saying that I like being historically correct and I really am happy to have you on this show because I think that you're someone that people will pay attention to and I think you're someone that deserves to have attention paid because you consider all the different aspects, not just the business, but of also reaching out patients through new media, of adapting, of transformative change and you have a care for the authenticity of the patient. So I'm happy to have you on this show early. How would you want to conclude with an audience about your thoughts of the new generation of REIs and what they'll mean to the changing landscape of the field?
HARITON: First off, thank you. I really appreciate you having me and I appreciate your words. I think I really like to conclude by saying that we need to embrace technology. We need to be willing to change. We have, as physicians, been the ones who have seen these patients for decades, we listen to their questions daily, we help them through tough times. And we also have to engage with the new entrants who haven't been through that, who are going to help shape the future of our field. We can’t think that just because this is the way that we’ve grown to where we are today, this is the only way of doing things, we cannot be passive and take care of patients and put our heads down because the field is going to move forward if we don’t engage. I think that as physicians, we have to be active partners to our patients, to industry, to private equity to the Silicon Valley startups and help drive the conversation in a way that keeps the patient first. I think that is the way that we're gonna be able to move this field forward. That is the way that we're going to be able to embrace the hundreds of thousands of patients that are going to be knocking on our door in the near future. And by using technology like artificial intelligence, like a lot of what David Sable invests in, we're going to be able to modernize the process and do it so that REIs are taking care of the top of the value chain, but we also engage over providers who are able to help us take care of this demand in a way that is safe, in a way that is patient-centric, and a way that makes sure that everybody who wants to build a family whether they are at the beginning or at the end of the journey, is able to do so.
JONES: Eduardo Hariton, Thank you very much for coming on Inside Reproductive Health.
HARITON: Thank you, Griffin. Great chatting with you.
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 fertiltybridge.com to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.