A significant issue for the business side of health care is the corporate practice of medicine (CPOM). In earlier episodes, we explored the most common solution to CPOM – the management services organization (MSO) model. Most often, these scenarios involve non-physicians owning the MSOs. In this episode, we look into instances where physicians own the MSOs. We share various physician-owned MSO arrangements and analyze the benefits and complexities of these different models.
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Listen to the full episode using the player below, or by visiting one of the links below. If you have any questions or would like to learn more, email us at info@byrdadatto.com.
Transcript
Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto. Legal issues simplified through real client stories and real world experiences, creating simplicity in 3, 2, 1. Welcome
Brad: Back to another episode of the Legal 123s with ByrdAdatto. I’m your host Brad
Adatto, with my co-host Michael Byrd.
Michael: As a business and health care law firm, we meet a lot of interesting people and learn their amazing stories. Brad, our clients commonly come to us with the latest word on the street that they heard from a friend. This season we’ll talk about stories with a common legal urban legend and seek to either prove or disprove the legend. This season’s theme is Fake or Real.
Brad: That’s awesome. Well, Michael, I think you’re going to be really excited today for the first time in a while, we’re going to avoid movie talk and jump into music talk.
Michael: Well just tell me you’re going to stay on Brandon, and we’re going to talk about 1980s music talk.
Brad: [00:01:00] Maybe. I make no promises either way. Michael, what is the first live concert you attended?
Michael: You just pigeonholed me into a 1980s. Music talk. Well, my first concert was in 1981, I believe. I haven’t checked it. it was the early eighties and I went to see the Police, the Synchronicity tour.
Brad: Yeah. That big timing in me.,
Michael: What about you?
Brad: Yeah, I had to think about this one, and I really think, which is kind of funny, I was in eighth grade or ninth grade and I can’t remember, somewhere in the eighties, but it was the Fat Boys. So for those who don’t know, it was a rap band. Okay, Michael what was the last live concert you attended? Oh,
Michael: Brad, this is just going to reveal the sadness of my life. So, I don’t [00:02:00] go to concerts for me anymore. And by the way, I have a feeling this is a major setup because you’re well aware of my life.
Brad: Sorry, I wasn’t paying attention to your life.
Michael: Yes, yes. So my youngest daughter, Alex, is a K-Pop fanatic, and I’ve been to more K-pop concerts than most teenagers, and so my last one was the TXT concert, Brad.
Brad: What’s the TXT?
Michael: That’s the name of a band. I’ve been to BTS, I’ve been to 17. I could keep going down the list and –
Brad: Are these, and forgive me, you know, I’m not normally the context guy. Are these all K-pop bands?
Michael: They’re all K-pop bands.
Brad: So you didn’t like mix a little country in there, or Western or whatever else?
Michael: Not recently. I mean, I’ve gotten to the Stray kids, [00:03:00] not to be confused with the Stray Cats from the eighties. Of course, most people don’t know who the Stray Cats or the Stray kids are. Brad, tell me what your last concert was.
Brad: Well, this one similar to you my son and daughter Ellis, and I have Ellis, not Alex. And Madeline loved this band called AJR, and so we went to see them live at a concert. And I will say, unlike you, I actually enjoyed the concert. they did an amazing job. And I told my kids if that was the first concert live I’d ever seen, I would’ve been very impressed.
Michael: Very nice. Very nice.
Brad: Well, Michael, what is your favorite concert of all time? And I’m assuming it’s not the K-pop.
Michael: Ooh, well, I’ll say this. I didn’t say I didn’t like the concerts themselves, I just was not going on the concerts I chose to go to. They’re actually better than you would think. But doing a lot of them, [00:04:00] no, they’re not. And also, they’re not in my top. But to answer your question, no, they’re not my favorite concert.
Brad: So what’s your favorite?
Michael: But that’s a hard one. I mean, Synchronicity is a candidate, U2, I saw the Joshua Tree tour. I saw Peter Gabriel in Boston. But I think if I had to just think about best experience would be in college, going to see Jerry Jeff Walker at Green Hall, and I saw him. Those were pretty amazing concerts.
Brad: Oh man. Okay. Well, I’m jealous right now that, that last one. because that’s a pretty good one. I did see Joshua Tree also, which was pretty amazing concert. And if it’s not one, the top ones, it’s certainly up there. And then I did get to see the Rolling Stones.
Michael: I did too.
Brad: And in the Superdome on their “last tour ever,” which as we’re recording this, I’m sure they’re about to go do another tour. But yeah, so let’s go on from there, Michael. So at any of these concerts, did you throw [00:05:00] any objects on the stage, like a bracelet, cell phone, family members, ashes, or maybe your underwear?
Michael: My bra. I mean, is it at Seinfeld? It’s a bro, or man’s ear. Man’s ear, yeah. Yeah, I might have done that. You know, I mean, I’m a fan. What about you?
Brad: You know, I don’t think of anything crazy like that, but probably if you haven’t been paying attention, there is this new crazy trend happening at these live concerts, and for some reason, people think it’s okay to throw objects at the singers. So Harry Styles was hit in the eye by an object thrown at the stage while he is performing in Vienna this year. Making the lists is ever-growing crowd. We had, Drake was a target of a cell phone being thrown at him while he was on stage. A fan tossed a what appeared to be a contact of the ashes of their mother on stage while Pink was in concert in England. And she actually even paused and said, is this your mom? [00:06:00] And then Adele, you know, she’s right now in Las Vegas, and she basically told her audience, you know, stop throwing things up here, so it’s been kind of crazy.
Michael: Well, I don’t know if you saw, this is in July, there’s an artist, which I’ve never heard of. I only saw her on the news, who actually got hit in the face by a cell phone, and she had to get stitches in her eye. And it was all over the news because the concert had to stop down. She did report to her fans on Instagram the next day that she was all good. But what does throwing man’s ears and cell phones at the audience have to do with today’s show?
Brad: Well, for first, for those who don’t know, Riley, our editor and podcast coordinator is a huge Taylor Swift fan, our major swifty sitting over crossroad. And first off, I pity the fool who attempts to throw something at Taylor at a live show. Riley would do some like jiujitsu takedown move on them. [00:07:00] And that person would probably be – she’s nodding her head in the hospital, or I imagine there’d be like, in slow motion, she’d be flying the air as she took the cell phone for Taylor to make sure, and she’s nodding your head. So, that’s what made me think about that.
Michael: Okay. Well, besides Kung fu Riley, anything else while we’re discussing all this?
Brad: Well, yeah, yeah. Well, second up until recently, everyone knew you shouldn’t be throwing objects at your singers that you love so much. And somehow that was lost. Well, something now is happening in the legal world. You know, earlier this season, we already addressed the question, fake or real, CPOM may affect my business structure of my med spa. And we spent some time discussing the utilization of MSOs and the model and CPOM states.
Michael: Well, first, before I’m curious before I talk about that, I am curious, Brad because I think I heard you asking this [00:08:00] just with all this talk, would you feel more famous if I threw my phone at you while we’re doing this podcast? Because I’m happy to do it.
Brad: I’m good with that. because I’m going to watch Riley try to save her favorite partner here.
Michael: I’m sure she’s going to stretch real hard. Sorry, I’ll get up back on track. You were talking about actual law stuff, right? CPOM and MSO. So, I mean, at a very high level a big issue in health care is this law called the Corporate Practice of medicine. We’ve talked about this in the other show. It basically regulates who can own a business that’s practicing medicine or exercise some level of control or influence over a business that’s practicing medicine. And one of the ways, the most common way that this is navigated, and when you hear about private equity and other business people coming into the space is through the MSO [00:09:00] model or the management services organization model. And the idea there is that you have a business that’s in the business of providing turnkey management services to a properly owned and established professional entity so that you’re complying with the laws on practicing medicine.
Brad: Perfect. Well, thank you Mr. Context as always. And what is fascinating is – so this whole sidebar conversations really has come up with when physicians start thinking about the legal implications. Thank you, Mr. Brad, of them owning their own MSO. And there’s some strong opinions out there. And so for today’s show, we’re going to address the myth fake a real, a physician can own an MSO.
Michael: Sounds great. And you know, I did catch you referring yourself in the third person, but you know, I’m used to that by now.
Brad: Yes, that’s true. Brad, it’s great. Michael, today our story, our main characters [00:10:00] are all plastic surgeons. Okay, these physicians all have their own independent plastic surgery practices.
Michael: Okay. Well, so how many plastic surgeons are we talking about in our story?
Brad: Six of them this time. And so several of these independent plastic surgeons actually own ASD together. And we’re going to call them these doctors. There’s three of them. We’re going to call them Doctors Pink, Drake and Adele.
Michael: Okay. Well, I think everyone sees very clearly what you did there, but you did violate a cardinal rule of our show by referring to an ASC without telling anybody what in the world you’re talking about.
Brad: You want me to or you, Mr. Context?
Michael: Go ahead, Brad. Tell us.
Brad: So for context, for those who don’t know, that’s an ambulatory surgery center or sometimes people call them a 23 hour facility. It’s a little bit lesser than a hospital, meaning the patient cannot stay there overnight, but they can have other surgical services performed there. So
Michael: They owned [00:11:00] the place, the facility where surgeries.
Brad: Got it.
Michael: So those three docs, we got Pink Drake and Adele doctors, excuse me,
Brad: The ASC owners. Okay, got it.So additionally there is this Doctor Swift Styles, and Dr. Pink, again, they actually own a med spa together.
Michael: Okay, trying to follow the bouncing balls. So we have, Dr. Pink is part of ASC and Dr. Pink’s part of the Med Spa, but we’ve got a couple of new people that are on the Meds Spa, so it’s not common ownership really across these two entities.
Brad: That’s right. You’re paying attention. Good job. Finally, Dr. Swift, Styles, Pink and Drake all work out of the same office, but with completely different staff and still fully independent.
Michael: Man, trying to follow this bouncing ball is very confusing, but I’m getting the picture, I’m getting the picture that we’ve [00:12:00] got this group of doctors, they’ve got ASC, they’ve got a med spa, and they’ve got their private practice or their office location. But in the office location, I’m saying this back because I’m just checking myself, Brad, they are separate.
Brad: You got it. So they all have their own separate plastic surgery practice, correct. So, but Dr. Swift and Styles they’d like to find a way to bring all these independent physician practices together, but the same time still trying to figure out ways to keep their own independent plastic surgery practice.
Michael: Yeah. And for, again, context for everybody in the plastic surgery world, the most common ownership of a plastic surgery practice; they’re basically like lone wolves. And so you’ll see single owners, or very small two to three at most owned practices. And so even a practice of six is really large when you look across the country, there are some that are [00:13:00] even bigger, but I mean, we can probably name on one to two hands the practices that have greater than six across the country. There’s probably more than that, to be fair. But it’s a relatively small number. And so, I can see them being big, but wanting to stay small. because that’s what their comfort zone is.
Brad: Yeah. And they had talked about merging at one point or a few of them partnering together in a medical practice. And each time they would start having these negotiations, they always fell apart. And legal implications, you know, besides those issues there, obviously there’s personalities and other growth issues that you have to deal with, with plastic surgeons.
Michael: Yeah. I mean, if you think about it, you could almost connect it to that lone wolf thing I just talked about. I mean, if you have a group of plastic surgeons that they feel they’re competing with each other. That’s the mindset. And so, [00:14:00] it’s hard to break away from that mindset when you’re all trying to go to the same pool of people to electively choose to get a surgery done. And if they don’t come to that doctor and they go to your partner or to the person you’re with next door, it can create this lone wolf mentality where you’ve got to protect yourself. And it’s harder to align and play well as a group.
Brad: Absolutely. And additionally, you know, the cost of running a solo practice, it’s really starting to become too much for these practice to bear on their own. And yes, there are state and federal government rules that they had to keep up with and that was hard for them to make sure, are they compliant? But since they didn’t seem to want to join each other, they just basically seemed to be at an impasse. And a few of them actually started discussing really closing their actual practice and just joining a hospital [00:15:00] just so they could shed their overhead.
Michael: So, I mean, they’re kind of stuck between a rock and a hard place if I’m hearing it right. I mean, on the one hand they want to be alone, but on the other hand, they can’t afford to be alone, but they can’t figure out how to work together.
Brad: You got it. He’s paying attention, Riley, he’s doing a good job today. Well, as a last minute push, Dr. Swift and Styles reached out to us and wanted to see if they could coordinate a call with all the plastic surgeons and find another option besides the merger for them to come together as a group or one entity. Again, I’m using their words. And so, as you can imagine, I recommended a whiteboard so we could draw out all their options.
Michael: And I’m going to – before I want to talk about the whiteboard, but I’m going to clarify all this buildup, we weren’t involved yet, right? You’re about to step into all the stuff that we started.
Brad: This all happened before they ever picked up the phone to spoke with us.
Michael: Got it. So we have the contact, so you’re like, okay, I see a mess. Let’s get on a whiteboard and we’re going to wipe – we’re [00:16:00] going to just map the whole thing out. And we do that, we’ve talked about this on other shows where our whiteboard meetings are essentially either in person or over zoom. We literally get in front of a whiteboard and start visually drawing out the structure and the flow of money and all those things to try to come up with a strategy or blueprint for whatever it is they’re trying to accomplish. So how did the whiteboard go?
Brad: Well you know, if I’m being honest…
Michael: Brad, you’re supposed to be honest with our audience, and we’ve talked about this, you know, you put these qualifiers in here, so you can feel free to not say you’re going to be honest, just do it.
Brad: Okay. Got it. Okay. It didn’t go as I planned. I kind of felt like I stepped into a bear trap from the start.
Michael: Okay. Well, let’s talk about – that’s kind of a term we use a lot here. because we heard some of our… one of our favorite radio [00:17:00] shows, The Ticket talks about it all the time. And it’s when you say something or do something and there’s something you don’t know where you get caught. And here, the bear trap literally probably was the fact that they were all independent and wanted to be independent, yet they couldn’t afford to be independent. I’m guessing you stepped right into the middle of that.
Brad: You wouldn’t believe it. Unfortunately, many of these doctors had arrived to the whiteboard already against the idea of quote, I’m using their words now, “partnering together,” and they didn’t need some Dallas attorney to tell them something they already knew.
Michael: Well, you should have just come in and said you were a Cajun and you spoke Brad.
Brad: I started speaking to them in the languages that they did not understand anyway, so it was okay. So based on these opening comments, I knew we need the to, to not go with the merger plan discussion. I mean, I, I just, I put that to the side and I kind of knew that was a bad start anyway. So instead I start off with… [00:18:00]
Michael: They threw their cell phone at your face, you decided not to talk about that.
Brad: So I tried to do something simple and I just drawing out, you know, what was the current model of each entity and who owned what, and what was the contractual relationship between the parties to have a factual look of where they were.
Michael: I love that. Don’t record that part Riley, but it is good. Like, when you are in that uncomfortable situation, at least you can say, okay, this is where we are, at least we can all come to hopefully a common ground on what we currently are.
Brad: That’s exactly what we did, Michael. So I had the clear picture of how they are divided up on these different groups. We start discussing what alignments they could have together and how they could share certain costs and staff and even certain supplies.
Michael: Okay. Gold star for Brad. You’re doing it good. Sounds reasonable.
Brad: Well, with this in mind, Michael, I stepped into the next bear trap.
Michael: What did you do this time, Brad?
Brad: [00:19:00] I brought up the idea of developing one entity that could help manage all their separate medical practices, the med spa and the ASC.
Michael: So you recommended an MSO is basically what you just said. And so, how is that a bear trap?
Brad: You wouldn’t think it would be, but Correct. I did say the MSO, but maybe not so much a bear trap as a small nuclear bomb, because what I didn’t know, again, is that several of these physicians were already, again, I’m going to use their words “familiar with MSOs,” and none of them had good experiences.
Michael: Oh, man. I’ve actually bumped into that before that you have that negative impression. So what happened?
Brad: Yeah, these negative reactions sprang from different experiences and myths. For example, Dr. Drake originally came from a large group practice and they were managed by an MSO and that MSO was owned by non-physicians. And Dr. Drake believed these non-physicians did not [00:20:00] understand his cosmetic practice and was running the group, but more importantly, his portion of the practice incorrectly. And as such, only non-physicians ran MSO and they did so poorly.
Michael: Okay, got it.
Brad: So then Dr. Pink had had some physicians friends invested in MSO and the federal government shut them down because they were illegal. And as such, in her mind, all MSOs in which physicians are a part of were illegal, and therefore doctors should never own them.
Michael: So you got poorly run and illegal and owned by non-doctors?
Brad: You got it. And then finally, last but not least, Dr. Adele friends tried to start an MSO but abandoned it because it was too big of an administrative burden, and they were also concerned with the model that would also violate certain federal regulations. So second, it was very – and very passionately about it.
Michael: Okay. Yeah, it sounds like it. Well, we’re kind of hitting this critical moment in our podcast, Brad, today, [00:21:00] our episode where it appears that the MSO’s not going to work with physicians owning it, and that you had a near riot started in our office. And this brings us to the myth busting moment for the story for Dr. Swift, Styles, Pink, Drake and Adele. Brad, is it fake or real, a physician can own an MSO.
Brad: It is real. Physicians are allowed to own an MSO and there are several legal models they can use.
Michael: Alright, fair enough. Let’s go into commercial. And on the other side, talk about the legal implications of the MSO model and want to know what happened with Dr. Swift, Styles, Pink, Drake and Adele’s deal.
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Brad: Welcome back to Legal 123s with ByrdAdatto. I’m your host, Brad Adatto, with my co-host Michael Bird. Michael, this season’s theme is Fake or Real. And Michael, today we heard a story about five doctors, Dr. Swift, Styles, Pink, Drake and Adele, and their quest to unite.
Michael: Yeah. I mean, the quick recap of the story is you’ve got this group of doctors, they’re all plastic surgeons. They all have this kind of lone wolf at heart mentality like most plastic surgeons, yet they’re trying to work together. And they have these different kind [00:23:00] of odd ownership things that, you know, three of them own a surgery center together, an ASC; three of them own the med spa together. And then they’re all sharing office space, and they’ve been trying to figure out how do we unite because we have some costs, it’s getting too expensive to run our own practice. So, how do we make that work? And yet they didn’t want a partner and they had bad experiences. You tried to help them stepped into a massive bear trap because they were all already emotionally about to detonate by the time they walked in as you tried to pose some solutions. But Brad, before the commercial break, you mentioned that there’s more than one way for physicians to structure an MSO model. And this is important because you mentioned the word MSO and they went nuclear as you said. They had their own picture of what an MSO is based on their experiences. So, let’s first [00:24:00] demystify what in the world an MSO is and what are these different ways that you can use it?
Brad: So each one of these models audience members understand are models in which a physician can own. Doesn’t have to be. But the first plan, Michael, I’m going to address is called the Master MSO plan. Now, the master MSO plan is utilized when planning to have multiple locations operating in multiple states, or there are multiple different owners for each location. And it solves a need for one entity to oversee each location, utilizing some of the same resources and intellectual property, but that one entity would be that master MSO.
Michael: I mean, under the MSO plan, as you said, master MSO typically owns the IP and has the key officers and administrators and the master MSO kind of is this back office and manages the activity for all the locations across the different states. [00:25:00] And you can sometimes have more complicated structures even under this MSO and on a state by state basis. Many times a master MSO may have large investors and several sub MSOs based on the locations. And in this situation, the Master MSOs typically the flagship entity where the founders are located, and it’s kind of the starting point of the business. And given that the Master MSO owns all the IP, the trade names, the website, the emails, phone numbers, it allows the sub MSOs kind of via these sub management services agreements to utilize these assets. And so, the sub MSO then enters into a main management agreement with the professional entity. So, it’s a little bit more [00:26:00] robust of a plan. It’s for a more sophisticated model. Talk about, let’s go – you said there’s multiple types of plans.
Brad: Yeah, sure. And so that one as you said, more robust. So let’s take another plan, which we call the control plan. Now, often the control plan comes into play when you have a physician or physicians or providers that has a practice, and they want younger partners to have the ability to buy into the practice. However, they also want to ensure that management and administration of the practices controlled by those with the knowledge and experience necessary to help keep that business decision on behalf of the practice. And so for this control plan you set up where the founders, they’ll form an MSO and intern to a management service agreement with the practice. And then the younger partners then are allowed to buy into the medical practice, but not the MSO right away, leaving the desire control on the management side by the founders. And eventually, of course, there are other options.
Michael: Yeah. I mean, and this can [00:27:00] be a great idea to use when you’re, to your point, you’re trying to separate out the control aspect of things so that it gives you the freedom to sell and bring in the young doctors into usually an equal ownership. And so, it becomes important when you bring – you have this MSO and you have this practice with the new doctors that you have a really transparent arrangement on the management services agreement between this MSO, between the founders and the professional entity that everybody owns because you can really start to create some trust issues if there is a lack of transparency. So, for example, the management fee needs to be, if the founders are going to take charge money to control manage the business, it needs to be super clear what the fee is going to be so that [00:28:00] everybody’s on the same page and aligned in a model where you have two different entities in play.
Brad: Yeah. That’s a good point. And so, another plan, Michael, we call it the Asset Protection Plan MSO, and this plan is used after weighing one’s risk tolerance. We’ve talked about this before. Everyone has different risk tolerance. Some people are afraid to step out of the shower in the morning, and other people jump out of a perfectly good airplane. But many business owners seek ways to protect their assets. And on the personal side, they may have a strong estate plan with trust and family limited partnerships and other ways to protect their personal assets. But on the business side, these same individuals may want to look at another way to protect their business assets.
Michael: Yeah. And we’ve got some clients that’ll do that. And if you own a medical practice, your two biggest risks are your employees and your patients. And so the idea with the asset protection plan on the asset protection side is, well, if we form an MSO, [00:29:00] that by the way, is not allowed to practice medicine, so it can’t be treating patients this entity. And this MSO has all the assets, and let’s say you take it a step further and leave all the employees in the practice. So you make the practice kind of the risk epicenter, so to speak, of the model. And then you have this MSO that has your assets and the physician has that level of protection. And sometimes, they’ll even layer in the estate planning side with their family to transition the business into the MSO and have family members that start to own an interest in that MSO entity.
Brad: So I’m going to go to the last plan, Michael, which is the glue plan. Now again, these are our terms audience members. And the concept behind the glue plan is that there are multiple partners who own different independent entities, but they work collectively together in some way. They’re separate doctors with their own professional entities, but they may share space or in med spa [00:3:00] or physical therapy or another company together. And the glue plan is the best use where the partners have a common business purpose between them, yet legally independent and the MSO functions as uniting business, the interwoven relationships are pulled together by this M SO allowing the partners to pull resources for the benefit of the group and share costs like admin.
Michael: And the key is, the MSOs in this glue plan isn’t really making money, it is just a cost center, right? Like you’re putting these shared resources in there, and you might even have upper-level management if you grow like CFO, CEO, COO as a resource. But it’s a place where you can get the benefit of sharing costs together, yet it’s not trying to make money like some of the other plans where the MSO is trying to make money.
Brad: That’s a great point.
Michael: So Brad, as we [00:31:00] kind of wrap up our episode today, what happened with Dr. Swift, Styles, Dr. Pink, Dr. Drake, and Adele? Because when we last left it, it sounded like the MSO was about to detonate. I guess at best, maybe it was on life support. I don’t know if there was any.
Brad: Well, luckily Dr. Brad was in the room, and I arrived and recitate the MSO idea.
Michael: Third person once again.
Brad: And at first I had to break those many negative beliefs that these physicians brought to the table about the MSOs in general. But most importantly, you know, the MSO model must meet the form and substance of which was needed for this deal. And as we’ve talked about it, no two MSO deals are exactly alike. But once they accepted it was legal for a physician to own MSO, we spent the rest of the whiteboard drawing out the glue plan on their current facts in the model. And they actually love the concept of continue under their separate practices and the ASCs [00:32:00] and med spas where they had some joint relations, but certain costs between the parties would be shared, and that way was offsetting some of the burden that they were carrying. But Michael, we’re out of time now, so what are your final thoughts?
Michael: Well, if you are someone who is looking for planning and you are wanting to give some advice, do, if someone mentions the MSO, do not throw your cell phone at them. Listen and hear it out. And I promise you, by the end, especially if it’s Brad, you’ll be throwing your man’s ear at him.
Brad: I do not see that coming. Well, audience members, that is all the time we have today. Next Wednesday, we continue our quest to determine if a legal myth is fake or real when we address medical estheticians can be delegated treatments in a med spa. Thanks again for joining us today. And remember, if you like this episode, please subscribe, make sure to give us a five star rating and share with your friends.
Michael: You can also sign up for the ByrdAdatto newsletter by going to our [00:33:00] website at bertadatto.com.
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