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What if your clinic could see 80 new patients while saving 80 hours of physician time… per doctor… per month?
That’s what Dr. Mark Amols and his team at New Direction Fertility Center are working toward—while maintaining a 9 out of 10 rating across hundreds of patient reviews.
In this episode, you’ll hear:
The top-of-license model (From REIs to admin staff)
How to structure visits to dramatically reduce physician hours
What operational efficiency really means for patient experience
The role of cost, time, and medications in improving access
Why combining new patient and follow-up visits might be the next major shift in efficiency.
Dr. Amols proves that operational excellence is not the enemy of humanity in medicine—it’s what makes it possible.
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Mark Amols (00:03) we see somewhere around 80 patients at least per doctor per month at least. So it would be 80 hours we would save. So now we can get more in. We don't have a long wait list anymore. That's the problem. That's why I talked about bottlenecks. Where's the bottleneck? A wait list. If you have a wait list, then you have a problem. Your REI doctors don't have enough time.
Griffin Jones (00:33) I won't feel sorry for those that don't take advantage of today's episode. I'm always sorry to see unnecessary suffering and the fantasy of I told you so is never actually sweet in real life. But those who resist IVF becoming a high volume field of medicine have had ample warning. If you're the REI, you're the one who should be making decisions about what's necessary for quality of care, not some business person. But if you think quality of care is sufficient with the status quo, it's not. 90 plus percent of people who need IVF can't get it. This is probably the fourth time my guest has been on the program. First time he came on was with Drs. Kilts and Magarelli during a sold out live episode during the pandemic. Since then, he's grown his practice, new direction fertility center to multiple physicians, thousands of IVF cycles. It's a very viable business. He's figured out a way to do that, providing IVF at a much lower cost to far more people. If you're a clinician, you can judge the clinical quality, but he's doing something right because their practice has a nine of 10 rating from hundreds of positive reviews. Each subsequent time he's come on the program, he's given more actionable advice. Today, Dr. Mark Amols applies the concept of top of license, not just REIs, but to everyone in the practice. He goes through what every level should and should not be doing, REIs, OBGYNs, nurses, medical assistants, and administrative staff. How many new patients Do you see a month? 20, 30, 40? Dr. Amols tells me he and his docs see 80 new patients a month each. What is he trying now with this top of license concept and some new tools? Combining new patient and follow-up visits to one 30-minute visit. How many hours does Dr. Amols think that's going to save them? Up to 80 hours per month per doctor. How many more patients could finally get IVF? If everyone did that, how many more babies would be born? How many people would finally get to be parents after years of wasting money, feeling like crap, not being able to afford IVF, not being able to get into a clinic? If more people did that, what could you do to globally improve operations in your network if you finally had some of that time back to sit, think, and work on the big picture? I asked Dr. Amols about a company he likes called Meitheal Pharmaceuticals. They're not new, but maybe they're new to you. And Dr. Amols shares why you might call your pharmacy and ask them if they'll carry Meitheal's products because medications have to be included in the conversation about access to care. Definitely don't try to spell it. Just remember the name Meitheal I'll of course have Dr. Amols back on because he clearly shows that operational efficiency is not contrary to, but necessary for increased humanity in the delivery of care. I want to hear what you think about the show. Enjoy.
Griffin Jones (03:50) Hailing out of the great state of Arizona, coming back to Inside Reproductive Health for at least a fourth time, I think. Welcome back, Dr. Amols. Mark, it's good to have you back. You planted a bug in my head the last time that we spoke. I don't know if it was a year or two on the podcast, that is. And we're talking about top of license. And we talk about top of license a lot in the field. We're almost always talking about...
Mark Amols (04:01) Nice to be here, Griffin.
Griffin Jones (04:17) the REI, the REI should only be doing those things that the REI has to do. you got me thinking about it's not, it doesn't end there. Like if it ends there, then you're not really picking up that many gains. You have to go all the way through the practice, all the way down the accountability chart that everybody's working at the top of their license. Tell me a little bit more about that concept.
Mark Amols (04:46) Yeah, we were, I remember which episode was we were talking about how to reduce cost. And one of the things that came up was this idea of having people in the role that you could have someone else in the role for less cost. And so this is where that top of license, you know, discussion came up with. And so when we first started doing it, it was more about, you know, not having someone like a nurse room patients because I could pay someone less, but more important, putting people also in the best position to be able to help our patients, make them feel more confident with the people they are. And I think part of the thing we want to talk about is, you know, what are the difficulties that come with that? You know, because obviously there, you know, people want to do everything. They like being able to do a lot of stuff, but obviously it's not very cost-conductive to a clinic. And it's also, it actually slow things down.
Griffin Jones (05:41) So is it more helpful to start at the top of the accountability chart and thinking about the REI and work our way down or should we start with the person answering the phones at the front desk?
Mark Amols (05:53) Yeah, I think the most important part here is this kind of bottleneck effect, right? So in your clinic, there's a point where there's a bottleneck, wherever that is. So for like me as a physician, there's only so much time in the day. And so if I'm wasting my time doing things that someone else can do at less cost and more efficiency, that doesn't make sense for me to do it. So I don't think it just starts at the physician, but I think that's the most expensive spot and the one with the with the biggest bottleneck, right? Because I mean, right now everyone is dealing with issues of, you know, seeing enough patients. And what's unique about our field is there's a lot of rapport that has to be created with the patient. And so we're even looking at like a company, for example, Levee Health. We're looking at them now to actually talk about top of license. I'm sitting there intaking the patient, basically, asking them about their history, making sure things are correct and stuff. And now we're thinking about using this company to do all that for us. So when they come in, I'm basically just building a tiny bit of rapport and starting off by discussing what the treatment should be. And you're actually trying to get rid of one of those steps. it's a little bit different than the top of license, but it's still that same principle of, we maximizing not just what we can do and how well we can do it, but is there someone else who can do what we're doing so we can just focus on what we're doing? And we see this throughout the whole field, right? mean, people are talking about OB-GYNs, you know. ⁓ doing retrievals and stuff like that. a lot of people, I know it's a very controversial position, but in the end, it is gonna allow clinics to be able to see more patients because there are certain things that you don't physically have to do as a fertility doctor. And so I say, yes, starting at the top is the most important. And just because there's a limitation on doctors, right? Same thing with embryologists. If you have your embryologist and all they're doing is paperwork all day, then you're basically limiting how many cycles you can do. because they're bogged down with paperwork. And so here's something where you can actually go and hire someone just to do paperwork. And then that way they can focus on being embryologists and can get more work done, which allows your clinic to be more efficient and usually even save money because paying an embryologist to do a lot of that stuff isn't very cost effective. Now, if you're a clinic who's doing very few cycles, like a boutique clinic, it doesn't matter. Right, you're probably sitting around all day or something like that. It's not a big deal, but if you're a clinic where you have bottlenecks, definitely work at the top of licensing and help your clinic in many ways.
Griffin Jones (08:23) What are those things that you were doing maybe earlier on in your practice or maybe when you were a fellow at Mayo that you felt like I shouldn't be doing this?
Mark Amols (08:34) Well, think everything you do as a fellow, you probably shouldn't be doing nothing like 10 % of what you do is your REI and the rest is scut work. But you bring up a question, I think as a physician, like I'll give you an example. One of the things I worked at a couple clinics. So I worked at a prior clinic with a great doctor named Dr. Kate Dumpetel. And when I worked with him, one of the things we did is we would do a lot of these visits that didn't make a lot of sense. I know they made money, but the one thing that you should never try to make money on is just your time. It's a waste.
Mark Amols (09:04) We're not lawyers here, so our time is the one thing we don't want to charge on. We want to charge on procedures. And we would spend time going over a lot of what we the fluff in REI. That's the, know, explaining them how the IVF cycle is going to go, explaining them how the medications and stuff like that. And we would do this. We would call it an orientation visit, and we would go through the entire process with them. And I realized one day, I this doesn't make any sense. I didn't go to school for this long to explain something that any nurse can probably even do better than me. I'll have better bedside manners than me. And let me let them do it. And we did that. And not only was patient satisfaction elevated, but we were more efficient. I could see more patients now, because now I had more time. And so that's one of the examples where I feel like even at another practice, that was very helpful for us. We've made some other major changes in our clinic and we constantly look at those factors of, we see more patients? What's the amount of time we're putting on that? How much time is being wasted? Another example was, when we first opened, everything was through phone calls. And listen, a lot of people love phone calls, and I get it, I would love to talk to doctor every single time too, but it's a lot of phone tag. And having my nurses have to constantly be trying to call people and go back and forth, it made more sense to go to a system that was more of text messaging system. And then once we switched to that, all of a sudden we had more time, my nurses had more time. And so all of those steps are all just to make sure everyone is able to work efficiently. but also be able to work at the top of their license. And now my nurse is gonna focus on ⁓ educating and making sure cycles are going well versus playing phone tag and basically on front desk.
Griffin Jones (10:40) In case it isn't obvious, why should doctors focus more on procedures and charging for procedures as opposed to charging for time?
Mark Amols (10:49) I mean, I there's a couple of things about that. I mean, the first is, again, amount of revenue. You're never going to be making the maximum revenue you're going to do. And again, I understand a of us don't care about money. I don't either, but I still need to pay people and I still need to have a successful business. And so part of it is that from the revenue standpoint, there's only so much you can charge for your time. There's some special doctors out who charge $1,000 for an hour. That's great. And they may do well, but for most of us, you know, we're not going to make as much. Whereas if I do a procedure, I can do, for example, a sonohistogram or HSG, which takes me eight to 10 minutes. And you're making somewhere between four, $600. But you know, if you're doing a consult, you know, you might make 250, 300 of your clinic charts a little bit more. It just doesn't make sense. And you're spending 45 minutes to an hour talking to them in an appointment that you can possibly do in about 10 minutes. Almost every single fertility doctor, guarantee you in about 15 minutes can tell you exactly what the patient needs just by looking at their chart. But the problem is that's not how the medicine works. Patients wouldn't like that. So instead we spend some time, we talk to them, we make them feel good. And it is in some ways a waste of our time, but it's necessary. I'll give you an example where we haven't changed. So if we were a smart clinic, one of the things we would do is we would stop doing our ultrasound. So as physicians, we do a lot of our own ultrasounds during IVF. It's not the best use of our time. We've looked at things like cycle clarity and stuff like that, maybe to speed it up, but in the end, it's not the best use of our time. But the benefit to the patient and the satisfaction to the patient is so high that we realize that five minute interaction is enough to sell the patient. feel like, man, like this doctor's here with me. They feel like they're the only patient at that time. And so we've kept that. But we do realize that does take some of our time. So that's a situation where we aren't working at the top of our license, but we're doing it for a different reason.
Griffin Jones (12:49) I want to ask more about that example because Tom Molinaro from RMA brought up the same example in an episode as well. And I was a little bit curious about it because if I'm a business guy that's coming in and not letting doctors make decisions and just saying, let's do this for efficiency, that's an area where I'm saying, don't be doing ultrasounds. And it sounds like that five minute impression is really, really important. Dr. Molinar was expressing a similar sentiment to what you said. I look at your reviews though, Marc, and they're really good. I don't know what your net promoter score is, but I can see from Google Fertility IQ, talking a 9.1 out of 10 on Fertility IQ, 4.6 out of 5 on Google. And it's not from... five reviews either. You got 159 Google reviews on Google. You've got 131 reviews on fertility IQ. And those are like actual numbers. Like anything above a 4.5 means that they are advocating for you. It's the equivalent to a nine or 10 on the net promoter score. whatever you're doing, like you've clearly been able to... That personalized attention you've been able to somehow scale that through the rest of your team. Why don't you think you could do the same thing with an ultrasonographer or a team of ultrasonographers?
Mark Amols (14:20) Yeah, so I've had an ultrasound before and again, you are right. If I put my business hat on, we're done for doing ultrasounds. We are. I think, know, psychoclarity, that's a great option for some places where one person does all the ultrasounds and we've actually considered that. One of the things we considered was instead of doing the ultrasound, having the patient do the ultrasound with an ultrasound using like a psychoclarity. And then we come into the room, they go into a separate room. We can talk to them for two, three minutes, tell them what we found, answer any question, let them go on. So that is something we're actually even considering right now, but we're testing it. You know, I actually talk to patients sometimes, I ask them what did they think? And they said, no, they'd rather see us. So part of it is, you know, when you're running a business, as you said, to keep that kind of high scores and people's satisfaction, if you get pregnant, you almost don't care. But the people who don't get pregnant, The first thing I always hear from them is, I've never even saw my doctor. I've talked to you more today than I talked to my other doctor. It's a big thing that comes up all the time. So patients really appreciate that time. Unfortunately, that consult, we were talking to them, but they want to know how things are going and there's ways to do that. So one of the things we did, again, top of license we're talking about is instead of every time something's not going well on the ACG or with the reports on the embryology reports, We've actually had a nurse practitioner who takes over a lot of that. And we've had great patient satisfaction because she can answer all those questions, which reduces the amount of questions we get. Whereas prior to that, if someone had embryos that weren't very good on day five, mean, my phone would be getting blown up by, the patient wants to consult right now, they're worried about this. And now we put someone in a position that can answer a of those questions and reduce the amount of time I have to put into that. ⁓ back to the point that you were saying, there's that balance, right? You have to have that balance between quality and efficiency. And again, there's gonna be a point where maybe we won't be able to do all the ultrasounds, but right now we can. My favorite example, I would say, of top of license was medical assistance. Every clinic has to use medical assistance. I see a lot of doctors sometimes use nurses and medical assistants, which again, horrible idea. way too expensive to have someone come in a room with you and stuff like that. ⁓ So medical students are really good. You can teach them, they can get great at everything. And sometimes we think of them as kind of, I don't want to say the lowest on the totem pole, but when it comes to education, the amount they could do, they're definitely on the lower side ⁓ for about the knowledge base. But in reality, they still have a lot of knowledge base. And so we started realizing, what are they doing that doesn't make sense? And so we realized putting people in rooms. We realized that it doesn't make any sense. They're spending their morning rooming patients, putting them out. You can teach anyone to room a patient. And so we did that. We started a new position. We called it patient liaisons. And what we do is those people, hire them basically off the street, no prior medical knowledge needed. They come in, we teach them a little bit, and then they room all the patients. And it's been one of the best things for us because now when they come out of a room, There's someone standing there waiting for them, calls them by name, tells them where they're going go next, say, we're going to have you now go do a blood draw. And they feel like they're the only patient in our office. Even though they see 40 other people sitting out in the waiting room, they feel like they're the only person because at that moment they are. But that's something where we pay less now to do it. And I freed up my medical assistants. And so if you looked at our volume and you saw how many staff we have, you'd be shocked. But it's because we have the medical assistants at the top of their license. They're doing the things that a medical assistant should. Nothing's beneath people. think that's the important part to understand. There's nothing, I'll pick up dirt off the ground. It's about efficiencies. And what I try to teach my staff is we all are working towards the same goal, which is helping these patients. And it doesn't matter what role you are, it's important. I actually tell my patient liaisons, they're probably one of the most important people in our clinic because they're the ones who make the patients feel like it's just them.
Griffin Jones (18:26) You can make all of these efficiencies as you are. You also need other people in other areas of the industry to do their part and innovate and bring in different and other things into the market. know on the pharmaceutical side, you're a little bit familiar with Meitheal pharmaceuticals. Tell me a little bit about how you work with them.
Mark Amols (18:49) Yeah, so we're really excited by them. ⁓ They are on the same mission as us, which is making fertility affordable, making fertility accessible. And so one of the things that's unique about our clinic, especially when we first started, is the cost for doing IVF with us was less than the cost of the meds. Now it's about even, but the point is that some patients go, can afford the IVF, but I can't afford the medications. And so definitely looking forward to competition and what they're gonna bring in this competition. We know when competition comes in, helps other prices go down. You can look at Ganarilux. They dropped their prices and all of a sudden, other companies had to start adjusting their prices as well, et cetera, things like that. And so we've been working with them and we looked someday to potentially be able to package everything. And we can just have one price, they get their meds and everything.
Griffin Jones (19:39) What do you think was missing in the marketplace before that? Just not enough competition to help expand what patients have options for?
Mark Amols (19:51) That's absolutely, it's competition and the fact that the pharmacy, and I won't go deep in this because I'm sure everyone probably knows, but it's a different type of system. These pharmacies, they don't get their money back till later. So they're basically giving a loan to these other companies. And so what happens is the prices are higher, there's more risk and stuff like that. And so ⁓ you can right now, I mean, again, I'm not telling anyone should do this, but you go to Canada, go to Europe, the cost is about a third. there's just, unfortunately, we don't have, and not that we should have regulation, but we just need some competition. And so when those generics come out and things like that, we're going to be able then push these other companies to make better meds or different types of meds and that competition is needed. And that's what they're going to bring. Griffin Jones (20:37) Okay, so you are working with NPPs, you're even having like the medical assistants ⁓ not be rooming patients so that you can have more customer service oriented people doing that. Is there a layer between the APPs and the REIs? Do you train OBGYNs? Do you work with OBGYNs? Do you see that as a layer in the future if you don't?
Mark Amols (21:01) Yeah, I mean, I'll give you my two cents and I'm sure not everyone will agree with this. ⁓ It's gonna need to happen. Anyone who doesn't think it's gonna happen will be left in the dust. There's just not enough doctors out there to have everyone REI, but I think this is where there's gonna be that little bit of an adjustment. ⁓ If you look at the anesthesia industry, you have your physician anesthesiologist and you have your nurse anesthesiologist. And the nurse anesthesiologist are kind of like that in between. And that's how I see eventually ⁓ this working with just regular OB-GYNs doing retrievals and stuff like that. I think what will probably happen eventually, and this is where I think we're doing it different than some other clinics. Other clinics are just trying to say it's the same IVF. We're not, we're saying, listen, this is not going to be the same IVF when we come out with it. This is going to be, it's a lower, a little bit lower IVF, but it's going to be pretty good, good enough for most people. And the complicated cases need to still keep coming to the doctors. And so just like we've done with our MPs where we have them doing like some histograms, ⁓ HSGs and stuff like that, ⁓ we would put these gynecologists into positions where they can take stuff away from us, but we could also still do what we do. So I think IVC is a great example of that. ⁓ IVC should definitely run by ⁓ Generalist OB-GYN who could do the retrievals, could do all the basic stuff and do the transfers.
Griffin Jones (22:25) And so what are OBGYNs doing in this instance if they're working with REIs and under REIs that they should not be doing that APPs should be doing? Mark Amols (22:38) Yeah. So I mean, for me, it wouldn't make sense to bring in a generalist OB-GYN to do things like the sound of histograms, the OB scans, the simple IUI visits and stuff like that. To me, it makes more sense for the MPs to do it. ⁓ But I mean, I truly believe, you know, MBs could even do transfers. I just don't think they can do retrievals. I think there does need to be some type of surgical training for that. For me, I think the biggest benefit of the generalist coming in would be kind of like the model you do in anesthesia. So for example, I'll be managing things. They'll be managing some of these ⁓ patients. say the ones are a little more complicated, have to do the retrievals and stuff like that. That's the ones the genitalia should do. REIs are gonna do all the complicated patients, all the complicated retrievals always being available. MPs can do on some other stuff. IUIs, IVC, even some transfers for IVC. Some clinics may choose to have them do the transfer for regular IVF. We don't, but like I said, It's not unreasonable. And what we're going to use the MDs for is mostly the retrievals and even some of the hysteroscopies and some of those things.
Griffin Jones (23:44) So then what are the APPs doing, often doing that they shouldn't be doing that a nurse should be doing?
Mark Amols (23:54) So ⁓ nurses can do things like IUIs and stuff like that. What we've found is, again, back to patient satisfaction, for some reason, a lot of patients don't like the nurses doing the IUIs. So it is something where the MPs like it. They feel like they're working at the top of their license when they do that. So we still have them do that. ⁓ I think there's a little bit of a crossover. I think when absolutes are going to be, don't, at least in my opinion, again, it not be everyone's opinion, I do not believe a APP as at least ⁓ nurse practitioner should be doing a retrieval. I think it's very reasonable with a course through maybe a PA if they've done surgery in the past, potentially, but I think that really should be left to the gynecologist or the REI doctors doing the retrievals just because there is some risk with that. And I think that would be the safest thing. When it comes to transfers, I don't think there's a difference. I think whether you have a ⁓ MP doing it or whether you have an REI doctor doing it, if it's a simple transfer, the rates are the same and that's what we've seen. We actually have our MP does IVC cases. Interventional culture cases and her transfer rates are spectacular.
Griffin Jones (24:58) Do you have an opinion on who should be doing the initial visit and who should be doing the follow-up?
Mark Amols (25:05) Yeah. So that's actually, again, where we come back to the top of the license again. So we used to even say like, you know, should we have the nurse practitioner do the initial visit? And then the doctor says the follow up, that's where companies like Levee health come in now. So like, for example, what they do now is they gather all the information, they get all the testing done. And then when you see the patient, you're ready for treatment. And that's a real, that's a more efficient model. You know, what we were doing before was we were doing the initial consult, we were ordering tests, then we were coming back and ⁓ doing the follow-up. Honestly, all of this can be algorithmic. When you first get the patient, get the history, you can figure out all the tests you need to do right then, have them go do the testing, and then just show up for the follow-up to be able to start treatment. That would also shorten your time for the initial visit because now you know what you're talking about. You're not just talking about all the potential possibilities that you do in the initial visit. Normally, you're talking about, it could be this, it could be this, we're gonna check this, this is what this test is gonna be. Now you can say, here's the test show. What we need to do is we need to go on DivyF or IUI, whatever it is. And that way get to start treatment right away. And I'm not wasting my time.
Griffin Jones (26:14) Am I correct in understanding you that you think that with this automation you can condense two visits to one?
Mark Amols (26:21) 100%. And I would even say more than two to one. Let's say you're doing an hour for your new consult and 30 minutes for your follow up. It's an hour and a half. I believe you can even get this down to 30 minutes total, if not even 45 minutes at the most 30 minutes. So that means from the first day you see the patient starting treatment that next month by doing that. So you automate everything in the beginning and then you go straight into treatment.
Griffin Jones (26:44) Also in a recent interview talking to Dr. Harrington and him saying, one of the things that helps us the most is being able to let the patient talk. Dr. Mulliner also saying, need the patient to really open up in order to be able to, do think he can do that in 30 minutes?
Mark Amols (27:05) can because I do let them talk. And so my portion normally is going through, you know, discussions, learning about things, educating them, right. But now I can just focus on letting them talk because now I already have all the tests done. I already know what I'm going to do. So what I usually do is I would then start with the conversation of, you know, any questions you're coming in with, talk to them, you know, I might even just be a little jovial about something here or there in their history. And then the next part is we'll get to then what the results were and then talk about treatment. But in the end, they're not coming in with a lot of questions anymore because a lot of the stuff will already be figured out and we'll be updating them. So when we go through testing, we're always updating our patients. That way, by the time they come to that visit, they already know all the results and now it's just more of a discussion.
Griffin Jones (27:54) Have you done this yet where you've combined the two visits or you're in the process of testing it out with this new automation?
Mark Amols (28:02) We have done it ⁓ in the past for a few things, but this is the first time that we're gonna be doing it here where it's fully automated in the beginning. So this will be starting ⁓ in about two weeks actually.
Griffin Jones (28:13) Wow, that sounds revolutionary. How much of your time do you anticipate it giving back to you in a month?
Mark Amols (28:24) I I think about 45 minutes to an hour per patient.
Griffin Jones (28:29) So multiplied by what 30 patients so
Mark Amols (28:32) No, we see somewhere around about 80 patients at least ⁓ per doctor per month at least. So it would be about. Yes.
Griffin Jones (28:38) 80 per doctor, 80 new patients per doctor.
Mark Amols (28:43) Correct. Just new consults per doctor. Sometimes a little bit more. So, I mean, that's 80 hours we would save.
Griffin Jones (28:50) her doctor. Wow, that's incredible. That's incredible. What do you think? What do you think will be the most valuable place to put that time? is it? Well, do you think some of it is going back into? I now I can use this time to work on culture to work on global operations to work or do you plan on just putting it back into seeing more patients?
Mark Amols (29:14) That's right, been seeing more patients. So now we can get more in. We don't have a long wait list anymore. That's the problem. That's why I talked about bottlenecks. Where's the bottleneck? A wait list. If you have a wait list, then you have a problem. Your REI doctors don't have enough time.
Griffin Jones (29:28) Most people I think are afraid of the opposite problem, they? That they think if I don't have a wait list, I have a problem because then they're worried that they're not having enough volumes to sustain the business.
Mark Amols (29:43) No, I mean, I can see that happening. Obviously it's possible in some places. I don't hear that very often. I most of the time what I hear from people is they have a wait list and there's a doctor shortage problem. And so everyone's working on these efficiencies and ways to allow you to be able to see more patients, but also not be burnt out. I'll be honest, there are times I'll see just four patients in a day, a new consult, and And I'm more burnt out just by the exhaustion of just, I'm not gonna use the word listening, but going over stuff that I'm just like, why am I spending 30 minutes explaining this? I'd rather just get the test results and go over it, but I'm talking about every possible thing, because they need it. So by having them come in already educated, already learning some of the stuff, all automated, that first visit, I get to really shine on why I became a doctor. I get to teach them. with the results there and telling exactly what they need to do and their questions, we focused on that in the treatment, not every possibility that could go. mean, the common question for a patient is, what do you think is wrong? Could it be this? Could it be this? Could it be endometriosis? My friend has this. Could I have that? And then you can't just dismiss them. So you got to talk about those things. That's a waste of time. And so now we get to focus right on what's wrong. And I think that helps things. And I think patients like it better too. mean, we've actually... have patients say that they really like the fact that it gets them moved so fast and not have to wait months and months and months to get to treatment.
Griffin Jones (31:13) I might be inferring, but because your practices reviews are so high on these different sites, I infer that you monitor this sort of thing and make operational decisions based on the feedback that you get. Do you have an internal NPS system that you're doing even prior to reading reviews? are you, if so, how are you using it to make sure that as you make this transition from multiple visits to one that you're still keeping that patient satisfaction.
Mark Amols (31:51) Yeah, I we talked to the patients. ⁓ There was an idea we had and we actually kind of polled patients and just asked them, you know, like, hey, what do you think of this thing? Would you like that better if we could even get the cost down, ⁓ lower costs? And people said, no, they'd rather see the doctors. That was one of the decisions that we were looking at was taking the doctors away from the ultrasounds. And people even said that we even offered the idea of like, would we charge more if you want to see the doctor versus seeing the ultrasonographer for all your scans? And overwhelmingly, patients said that they wanted to see the doctor and that it would even be worth more costs. And so ⁓ we tend to do that. have internal, like I said, internal pulling the patients. We ⁓ constantly are asking for surveying our patients, asking questions, what things are like, ⁓ you know, and it's part of it in your system, you know, making sure that everyone understands, again, back to this top of license topic, the role in all of this. And I explain them, like, when I get these reviews and I get these feedback surveys, they're not like, oh, Dr. Amols is amazing. It's your front desk helped me through this. The fact that they were able to talk to me about this, your phlebotomist was crying with me. These are the things I try and make sure they know that don't look at it as that you're not doing a lot of stuff. Looking at it your job is so important, you're part of this whole system. like cogs in a system, if I take a cog and put it somewhere else, it might work, but it's not going to work as well. And so while everyone have in their position, it makes the system run better, which means when it runs better, you have more time. If you have more time, you can talk to patients more. And if you can talk to patients more, that makes them happier.
Griffin Jones (33:35) What do you attribute that culture to? What does your hiring process look like?
Mark Amols (33:40) You know, I won't hire anyone that doesn't smile. But I want to see a smile when they walk in, and we don't hire them. ⁓ I think that's one of the most important things. ⁓ You know, I try to make sure people are normal people, you know? And I want to make sure they understand, like I tell them all the time, our goal is to make a baby and help people have families. And if that's not important to them, I usually, you know, won't hire them. it's one thing that I talk about is in the top of license we were talking about is that although we have people in certain positions, when there is time available, they actually go around and work in other places. Like one of my medical assistants had a degree and I think it was biochemistry. And I told her, said, listen, you have free time. Why don't you go to the andrology, learn some of the andrology. Maybe you can cross cover over there. Are you having a desire to be an embryologist? And we've had people move up. One of our medical assistants actually starts a medical assistant out of high school. She's now one of our senior embryologists. So there is ways to move up through the system. And we encourage them to want to learn. One that come to other classes, cross learn. And again, but it's important for them to be efficient and that efficiency allows them to have more time than to focus on the patients. I've been in the operating room, so I think you know I was a nurse. And I remember when I was a nurse, I go and do a procedure with the doctor, do a little bit of paperwork, be done. Now I go to the operating room, I never seen the nurse actually work with the doctor. They're just constantly doing paperwork the whole time, the whole entire time. And that whole benefit of the nurse being there as an advocate for that patient is not there anymore. They're so busy doing paperwork. And so top of license doesn't just affect putting someone in the position. also giving them the tools to be able to do their job. So that means if you have an EMR that has 17 steps to do something and your nurse spends 15 minutes doing it, then you've just reduced the amount of time that nurse has to talk to the patient. So that's again, where that top of license was even letting them have that ability.
Griffin Jones (35:36) When you look at organizations that have the best customer service, they usually fit one of two profiles. Either it's such a tiny boutique, it's like it's the mom and pop that like my wife and I's favorite bed and breakfast. It's just incredible. It's totally unscalable business. It's just the fact that she's a world-class designer and cook and he's like can build and fix anything and they provide you with the best service. it's like something so small and they have just the talent that perfectly fits it. Or it's an organization that has operations fully in lock. You don't see organizations with really good customer service that also don't have really good operations because you can hire the best people and the nicest people. But if they have to be running around like chickens with their heads cut off, they're not gonna be the nice people for long. They just can't be. They can't provide people with the best attention. I feel like I have to somehow persuade some doctors or sometimes people in the space to look at it that way or maybe I need to get better at describing it. But often I think people see these is too diametrically posed. Like if I invest in technology, if I invest in so much about making it about operation systems, then we're taking away the human element. Like no, the entire point of making it so efficient is that you can be How do you think about operations and customer service as being two necessary components?
Mark Amols (37:24) Yeah, a hundred percent. mean, you know, obviously you have to have nice people, right? So that's the first thing is, you know, they're amazing people out there who would just have no bedside manners. And, know, if that's your goal in your clinic, then you need to have people that fit that. I think you hit the point with a boutique. If you're a boutique, you can kind of get away without great operations because usually in those situations, there's not enough volume that you can just on the fly, spend another 45 minutes with someone. I mean, I've talked to patients who've said they've spent two hours with another doctor. like, wow, like I don't even know how they do that. Do they just skip the next patient or something like that? But if you're a clinic who, you you want to grow, you want to scale, you really have to focus on the operations. And again, you have to think beyond yourself. I think that's the one area a lot of places make is they look at just the physician. Well, what makes the physician happy? What makes the physician faster? But end of day, you're just still one person in this entire system. And so really what you need to look at is even to the level of the EMR, you have to ask, it making us more efficient? Does it make my nurses more efficient? ⁓ Should we use scribes, task routing, all those different things to make the team faster? mean, we constantly, so I work, Dr. Salem and I, work together, Dr. Dermen, Dr. Johnson, we're always talking to our son, hey, what can we do different? Is there anything we can do? that you feel you're wasting time on, or you see the nurse's time being wasted. And we're constantly coming up with ways to make it more efficient. And again, that allows them to have more time to talk to the patients.
Griffin Jones (38:58) We've been talking about the clinic side with this top of license concept. How does it apply on the lab side?
Mark Amols (39:06) Yeah, I mean, same principle. So it's something I actually wanted to do. I don't, haven't done this yet, but I think Richard Scott did this with his lab where he put people in a specific situation. So let me give you an example. When you're, say, you know, we're to have a fast clinic. You might be able to do retrievals fast, but let's say ICSI, that's where everything bottlenecks, right? So we buy a lot of equipment. So we have multiple scopes. So that way, you know, we can have a bunch of people doing ICSI at the same time. But still there's a bit of a bottleneck. So we've talked about it, like, do we just put someone in a position to only do icksy? Become the best at icksy and have someone who just does freezing and who just does thawing. And that again, would allow the embryologist to do the other things to take more time. So again, doing BOPs slower, again, not long time, but more careful might be able to allow better rates. It's same principle I talked about with charting. Another thing. you know, making sure that we can make things simple. was currently, I'm actually creating a, ⁓ for andrology, a semen analysis worksheet. I'm trying to make it completely automated. So basically they put in just the first couple of measurements. It does all the calculations. It makes the chart for them. It sends out the letter, all those things with just one push of a button. Because why? If I can do that, and I'm currently writing that, then I know they have more time then to talk to patients or do other things.
Griffin Jones (40:27) So how do you think about as you bring on other people and ⁓ you brought on some docs and so at least within your practice, it seems to be expanding. Do you see this catching on your model catching on in other areas yet? I would have expected more people to copy you at this point. And part of the reason is I look at yours and again, maybe I'm assuming too much. I don't know your books and everything like that, but I If a 2008 style recession happened, like Mark's probably going to be in okay shape because you're at a place in the market where then other people are going to be coming from farther because you are at the price point that can deliver the quality of care that ⁓ they will be forced into at that point. If these Trump... IVF coverage ideas actually do come into fruition and mandated care actually explodes and giant payers are able to just tell everybody, here's what we're paying. You've got a huge head start in operations to making it ⁓ viable. Why don't you think more people have copied this model up to this point?
Mark Amols (41:47) they haven't had to. So if you don't have to, why change what works? mean, know, most...
Griffin Jones (41:51) Well then why did you, why did you if you didn't have to?
Mark Amols (41:54) So I saw this a long time ago, ⁓ years and years ago when my wife and I went through and we couldn't afford to go through, we were very fortunate that Mayo allowed us to use a payment system. ⁓ If we didn't have that, I wouldn't have kids. And so we, my wife and I felt like no one should not have kids because of money. And we said, it's, really costs us much. And we looked into it, we're like, it actually doesn't. Most of the expense is from the inefficiencies. And so when we started looking at it and making it more efficient, we realized we could do this for a lot less. of the only reason we've raised our cost is not because we needed it for finances. It was honestly just because people, interesting enough, if someone thinks something isn't worth something, they think it's worth less. So for example, we didn't charge for Ixie and people would say, it's free. And we're like, well, no, it's not free. We just don't charge you for it. So we learned we had to put some expense to some things to make it. So that's why our price is raised. But we're a volume clinic. One thing you mentioned was the price point. mean, honestly, we focus more on our rates. I mean, we have great rates. We compete with some of the best in the country. ⁓ So we never focus on the cost. The cost just happens to be our mission. ⁓ But regardless, even if you're charging more, you're still going to run into these problems. And so when we started, I realized this. When I make my offices, they're all made very similar, where we have rooms where a patient go from one room to the next room. And like for in my clinic, at any given moment, I can see six patients at any given moment, the way we have the room set up. And so I do about three patients every 15 minutes. ⁓ Sometimes I'll do only two every 15 minutes, but I can easily do three. And I'm able to do that because the patients leave one room, go to the other room for the instructions, then the room moments back up. And I'm able to just constantly keep moving and see all those patients in a short amount of time. ⁓ What I realized was we were going more to insurance. pretty obvious a long time ago. We're seeing a lot, you know, everywhere and it's going to happen whether it's now later. And with insurances, if you look at Europe, it's all about volume. And that's what everyone's gonna have to go to. Matter of we see already a huge percent of out of state patients. ⁓ lot of people coming from California, driving all the way here and just staying here the whole time and doing IVF with us. ⁓ And I think even when they get their mandate that kicks in, I think in July, all the clients are not gonna be able keep up with the volume. And again, they're gonna start having those wait lists and they're gonna have to start implementing these things and they're very easy to do. It just, it takes some time because if you're not doing it from the beginning, a lot of people don't like to do new things. And so it's a little frustrating at first. They feel like you're taking away certain responsibilities from them and you have to explain them and kind of teach them that no, I'm not taking something away. I'm actually putting you up on a pedestal and I'm now having you do a job that no one else can do. And that's why I'm putting you here.
Griffin Jones (44:44) Is that just the doctors that often feel like something's being taken away from them or do the APPs feel that way at first too?
Mark Amols (44:50) everywhere, everywhere, yeah, everywhere. People have been doing this longer, know, in another practice. It's a little bit more, you know, like, we didn't do that here. Why are we doing this? I can do this. I'm like, no, I know you can. I tell them, go, but I don't want you to do it because I can have someone else do it for a fraction of the cost and do just as good of a job.
Griffin Jones (45:10) Does bringing each seat up to their top of license make it easier or harder to cross train and have redundancy?
Mark Amols (45:19) ⁓ I mean, it's definitely, I think, a little bit harder. ⁓ But I think it's always easier to teach things below your license than it is above your license. So it's kind of like inherently as you learn the top of license stuff, you kind of already know the bottom stuff. You're like, yeah, I can do this. If I can do a sono histogram and a transfer, I can do an IUI. And that's the way I kind of think of it, is that as you teach somebody to be at the top of their license, inherently through osmosis, they kind of just learn the other stuff. And again, we encourage them when time is free to go and learn those other things, to cross train. So just in case if someone's down, we move another person in. But there's another benefit, Griffin. When you train someone to know too much, you are pretty much handcuffed to them forever. You know if you lose them, you don't lose one person. You're losing three, four people, right? Because that person has their hands in everything. When you have people who are more focused, you can train someone in that position maybe in a few weeks. But like in the beginning when I first started and I wasn't doing this, mean, it took me four months to teach medical assistants to be able to do IVF calendars, be able to do these things, you know? And when I made the switch now, someone leaves and can hate having them leave, but then maybe they moved. Within a month, the person's up and running and can do the same thing the other one was doing. And so we're not handcuffed this idea that like, We have to have this person. We know that we can train someone very fast back in that position because we're just having them do what they can do well, not having them have to learn every single portion in the clinic.
Griffin Jones (46:54) I don't know if you found this too, but I find it easier and clearer to hold people accountable that way. So in earlier iteration of my business, had a bunch of full timers. I didn't do things right. And I'll write a book about it someday. But I really took some lessons and built an operational system and built a management system and then built a cultural system that I've been using the last three years that I think has really worked. in this... ⁓ later iteration, what I decided to do was, I'm going to especially I'm in more of a privileged position than most clinic owners in that I have a remote business. So it is easier to hire part timers, it's easier to hire independent contractors. But I decided I'm going to hire multiple people, more people for smaller seats so that I can hold them more accountable. Most people business my size, they don't have an assistant and a sales assistant. But I do, and it makes sense because they're each part-time and they're each totally specialized. And then I can hold them each accountable for different things. And so as I started bringing on more people, I had them accountable for areas that I could then walk away from. And I liken it to, if you and I own a restaurant and we can only hire a handful of people and we have the host... ⁓ also serving people and also busing tables and also trying to help with ⁓ the line cook, then we can't hold that person accountable to any one of those things. I would rather hire one person and say, okay, you're the line cook. Your job is to make sure that all of the vegetables are cleaned, washed, cut, and set over here for the main cooking. then deal with the chaos as I start to systematize and grow that area, but at least I can fully walk away from that area. And then, you know, as they develop in capacity, then you can decide if you want to add on an additional seat, but there are two different seats. And so have you found that as well where accountability is clear when you have people doing more specialized roles?
Mark Amols (49:05) Absolutely. And that's really, again, that top of the license, right? Even, I won't even use it as a license. I'll give you the example of like authorizations, ⁓ looking at insurances. I can teach one person to be the best at this and then have them work over other people and they could just be focused on one part, you know? So we do this a lot with ⁓ remote employees. ⁓ You know, we realize that like when, know, cost is going up, like for example in California. You don't have to have a worker in California to do authorizations. You can go and hire someone from Texas remotely, have them do the exact same operation for $15 an hour versus $20 an hour or more in California. And there's nothing wrong with that. You have maybe one person in the office who is in charge of them. Make sure things are going well. You have the person who's accountable for that. And then the other people are the worker bees. They're the ones doing, let's say, some of the busy work so she can focus on making sure everything goes well. ⁓ We did this as well with some other things when it comes to like billing where you have, you know, certain people who are in charge and then the other people are the ones who do a lot of the busy work. I mean, there's even remote workers you can get from other countries for about $7 an hour. So again, it's not just about fish to see it's not. Yeah, we have, do that already.
Griffin Jones (50:17) Have you tried that yet? When I was at the arm meeting, not this past year, but the one before, people were saying, we love these people from the Philippines. Not only are we paying them a great wage for where they live, but it is a big cost savings to us. It's not just the cost savings. It's like, they're better. They're better team members. They work harder. They grow faster. at like, they're like, meanwhile, we're trying to pay people 35 bucks an hour in freaking Chicago. And they don't show up the second day. And so have you found that?
Mark Amols (50:59) Yeah, you know, it's gonna be hit or miss, right? I think the ones that allow you to do the interviews end up being better. I've had actually ⁓ surgeons in other countries and gynecologists who've worked for us in their country and they just kind of do it on the side. ⁓ The other thing that is, we actually just had one who was working in our billing department notice something we didn't even realize and say, hey, you know, I noticed this, you guys might be able to make more money with this. And we're like, wow, thanks for that advice. So mean, these guys really take this job serious. They love it because they're able to work from home, but still make a good salary for where they live. And it helps us out because we're not putting them in the position where something bad can happen, right? These are positions where they're doing some work. Someone's still watching over them. Like you said, accountability, but someone can do some of the busy work. They can out the paperwork, right? I it's no different when a doctor gets a form. doesn't make sense for the doctor to out the whole form. takes them 10 minutes to do, they could have spent eight of those minutes talking to a patient. Instead, someone fills out for them, hands in the form, they look it over, sign it, two minutes, they have eight minutes now to talk to another patient. Same principle here. If you were able to get someone for $7, $8, $10 an hour who does some of the busy work, the person you're paying the $35 hours watching over everything, now it's like you have three workers doing, you know, for the price of one or two.
Griffin Jones (52:21) You've talked about automation and some solutions. One of the folks being Meitheal Pharmaceuticals, them bringing in some ⁓ competition into the space. There's probably a lot of people listening that have never heard of Meitheal and they might ⁓ not even be that familiar with generics in the space or anything like that and might even have to ask their pharmacy partners if they carry them or if they would carry them. Is that worth it for a doctor to do? If it is, why would a doctor want to do that?
Mark Amols (52:54) You know, I think right now, it's like kind of the old boys club in the pharmacy field. So I don't think it's going to be as easy. think what you have to do is have to reach out to them. But I think the benefit is, again, we all know that some people get pregnant with IVF in the first try. But a lot of people need more than one try, but they don't have the money for it. So if there is a way for them to save money, be able to go through more than one cycle, you increase their chance of success. And that's what Meitheal will allow people to do, allow to get meds at lower cost. And I think ⁓ as the competition comes in, I think a lot of these pharmacies will be able to offer a little bit more. You have to remember in the pharmacy industry, there's a certain amount of meds they have to sell before, if they've tried to sell generics and don't sell enough of their other one, they could lose some of their contracts. So again, it's kind of anti-competitive in some ways. And so that's making it a little bit harder for these companies to come in and offer these generics.
Griffin Jones (53:49) The other solutions you talked about with regard to automation, is automation the first step? Do you think eliminate, automate, delegate? Do you go in that order? So before you even bring down the top of the license, you look at what can we maybe just get rid of entirely? then what can we automate? Especially as more tech is coming in, does it make sense to do that first or does it make sense to get people in the roles so that then you can maybe step out, take a look from the thousand foot view and then start automating what people are doing.
Mark Amols (54:25) I mean, obviously you can do things concurrently, but I think top of the license is the most important thing. I just, it doesn't make any sense to me of why you would, I worked at a clinic where you could not tell the difference between a medical assistant and a nurse at this clinic. They did the exact same job. It made no sense to me. That doesn't make sense. There's no reason for it. Even the patients didn't know which ones were nurses and which one were medical assistants. So at that point, it's nothing about being beneath them. Again, your clinic will run better if that... nurse could have had more time to talk to the patients while the medical assistant did some of other stuff. So I say start there. That's what I would think. With automation, the thing you always have to remember with every single one of these things is there are always unintended consequences to changes, right? And so you have to sit there and go, okay, what's going to happen if I do this? The goal is always to improve something. So even if it means someone gets to go home early, that's satisfaction of life. My embryologists know when they're done, they go home. I don't just keep them there because it's they're on salary. I said, no, if you're done, go home. No reason to stay there. And then that also increases satisfaction. So saving time isn't just to get to see more patients, but satisfaction. When Dr. Dermott at my clinic comes in at 8 a.m. and leaves by 5 p.m., more satisfaction than being there until 6, 7 p.m. because he's using, you know, ⁓ scribes and things like that to make it faster. He's able to get done with his notes, by the way. I automate things so he doesn't have to do anything.
Griffin Jones (55:51) What do you think will be the consequences of not pursuing efficiency to this degree for clinics in the next five years or so?
Mark Amols (56:01) Yeah. I mean, that's easy. That it's going to be what you see in any industry that has increased in volume. Any industry that goes into volume. If you don't have efficiencies, you'll just, you'll be crushed or you do with these other places and you make a boutique, right? So, ⁓ you know, as you mentioned, ⁓ the place you'd like eating at the boutique, right? You might pay a little bit more. ⁓ you know, you might not get your food in five minutes, but, you're boutique and that's why you were able to survive. And there will be boutique clinics and there will be clinics that are able to do volume because they're efficient.
Griffin Jones (56:35) There may be people that are finally coming around because you've proven this now. It's not like this is your first year doing this. You clearly have a viable, clearly have a growing practice. Patients are clearly happy about it. And so maybe folks that heard about you a long time ago, or maybe they saw you the first time on the podcast five years ago and they're like, ⁓ but now they're starting to, the wind is starting to catch up with where they're at. And they're like, all right, yeah, he's probably right. but it still feels overwhelming to them. Where should they start? What's the first thing they should do to actually implement this top of license concept in their practice?
Mark Amols (57:16) Talk to me, I'm not a competitive person, so I love competition. I love people coming to me, giving away my ideas, having them do it so that way they can implement it. It's only gonna help more patients and then pushes me to have to come up with more stuff. So, more than happy to talk to people about it. There's a lot of groups out there, practice management groups that can help with things as well, help you get to that. That's what a COO does in a lot of places, is just help some of those operations. You know, one thing that I haven't talked about, because something we haven't started yet, but we're even taking that level of top of license to the next level, something else that we're going to be bringing out soon. And you'll probably have me on again for that when that comes out, but it's a new philosophy even further than just fertility. And we think that's going to make some waves as well. And so it's just the same principle of how do you get, how are we able to see more patients, not lose satisfaction and be efficient. This is what everyone's working towards and there's more than one way to do it. It's not like my way is the only way.
Griffin Jones (58:16) And so what so this is like this is like a service or like some what what is this new venture you're alluding to?
Mark Amols (58:21) Yeah, think of it like a service. Think of it like a service. I can't talk about it because it hasn't come out yet. It's coming out soon. But yeah, like a service.
Griffin Jones (58:29) Well, we definitely will have you back on because you are not a person who who keeps all the secret sauce to himself. ⁓ It's one of the reasons why your episodes are popular. I look at different episodes. Some get more listens than others. And there's a reason why you've been back on multiple times. It's because you are willing to share specific. Sometimes I'll have people on once and like trying to get any kind of specific answer out of them that I cut. the interview at like 40 minutes because like, I don't like who's gonna listen to this. But people listen to your episodes the whole way through because you really do share this stuff. And so I hope people take you up on it. We'll of link to your website and we'll link to you on LinkedIn and all that sort of thing. And people can reach out to you directly if they're shy, reach out to me. I'll connect you with Mark. ⁓ But we absolutely will be having you back on Dr. Amols because ⁓ every time there's good actionable info. So thanks for coming back on the program.
Mark Amols (59:31) Yeah, hopefully I did help someone. And like I said, I've helped lots of other clinics before and I don't charge anything. I just want to help people.
