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Well, hi everyone. I'm Randy Kardas, CPA Systems Designer, and welcome to another episode of Beyond the Numbers. Now, I've heard in a lot of orthopedic partner meetings where a top producing surgeon says something like, I'm busier than I've ever been, and somehow I feel like I'm making less, and the room goes quiet.

Not hostile, quiet, more like nobody wants to touch it because it instantly feels personal. You can see people scanning the table wondering whether this is a compensation issue, a fairness issue, or something. They don't have the language to explain. If that sounds familiar, you are not alone. This shows up in well-run practices all the time, especially as groups grow and complexity increases.

Before we go any further though, I want you to know something important. This is exactly the type of problem my team and I help orthopedic groups solve every day. We work primarily with orthopedic and multi-office physician practices to redesign the economic systems underneath the reporting, so the numbers actually reflect how the practice runs.

That includes helping you select and implement the right technology stack. Often at very favorable terms because of the volume and way that, uh, we work in this space. Now, I'm not saying that to pitch you, I'm saying it so you know that there is a path out of this tension if you're feeling it. Because most of the time what looks like a compensation problem isn't about compensation at all.

It's a signal that the economic story your system is telling no longer matches the reality of your practice. High producers feel it first because they're closest to the operational load. They're pushing the system harder than anyone else. Today we're gonna unpack why this happens and what leadership can do about it before frustration turns into distrust.

So after working inside orthopedic groups, here's what I've learned. When high producing surgeons feel underpaid, it's usually not a compensation problem. It's a shared cost problem. Nobody can see clearly. Compensation is visible, so it becomes the focus, but it's just the output of a much larger system.

If the inputs feeding that system are distorted, the output will feel distorted, too. High volume surgeons generate more revenue, but the. Also generate more activity, more cases, more clinic flow, more coordination, more billing complexity, and more strain on shared resources. That activity pulls on the system in ways that don't show up neatly on reports.

Most practices allocate shared costs using rules that were built when the organization was simpler. Even splits, percent of collections broad averages, that might sound familiar. Those rules feel fair because they're easy to maintain, but as complexity grows, they start redistributing economics quietly.

So the physician creating the most operational demand can end up absorbing more overhead indirectly, while the reporting structure makes it look like. They're simply less profitable. This is where leadership gets stuck because everyone senses something's off, but no one can point to the exact mechanism.

When groups bring us in, this is often the first layer we examine. Not compensation formulas, but how costs. Follow activity. Once that alignment improves compensation, conversations become dramatically easier Again, this isn't about selling software. It's about making sure your economic framework matches the reality of how your practice functions.

One of the biggest misconceptions in physician owned practices is that cost scales neatly with revenue. It doesn't. High producing surgeons and physicians don't just generate more income, they generate more complexity. Every additional case triggers a chain reaction across the organization. So think about this.

Scheduling, coordination, staffing, adjustments, pre-op workflows, billing touches, administrative oversight, claims processing. None of that shows up as a clean line item on a physician p and l profit and loss statement, but it shows up in workload frustration. I remember in operations, a director telling me and half joking, we can't tell when Dr.

Dr. X we're gonna call him, ramps up his schedule because the entire building starts moving faster. That's operational load in real life. If your system isn't designed to capture that relationship between activity and the cost, the economic story becomes distorted. High producers feel like they're carrying something invisible.

Lower volume physicians feel like comparisons are unfair. Neither side is wrong. The system just isn't translating reality. This is why groups often come to us, not because they want new reports, but because they want reports to finally make sense when clinical activity and financial outcomes reconnect.

Leadership regains clarity. And clarity is what allows growth decisions to happen without hesitation. One of the fastest ways economics gets distorted in orthopedic groups is physicians assistant utilization. Maybe this hits a chord with you. Some surgeons and physicians rely heavily on PAs to expand.

Clinics capacity assist in procedures and manage follow-up care. Others operate with far less support. Both approaches are valid, but they create very different cost footprints when PAs costs are spread evenly or tied. Only two collections. I see that a lot. The numbers stop reflecting usage. I, I've seen sergeants say, I feel like I'm paying for PAs.

I barely see or barely use. Maybe they don't e they don't even work out of the same office. That frustration isn't about the people involved, it's about the logic behind the allocation. Operations teams often understand exactly how coverage is being used. Finance teams understand how the costs are being distributed, but the model connecting those two perspectives.

It hasn't evolved. It's not aligned. Once groups start aligning the PA costs with actual utilization, even as even in a simple way, tension drops quickly. The goal isn't to track every minute. It's to make the story believable. And what I mean by story, that is the profit and loss story when the financials are being reviewed with you.

Physicians don't need perfection. They need to feel like the system recognizes how the practice actually functions when groups work with us, that this is often one of the first areas we address because the impact is immediate. It's a clear example of how a small structural adjustment can restore trust across the partnership.

And trust is what allows leaders to move forward instead of reliving the same debate every month. That gets us to shared services. One of the biggest blind spots in the practice and is it's often how uneven the workload behind the cases actually is. On the surface, revenue looks like the primary driver of value, but operational effort often tells a very different story.

Not all cases require the same number of touches. Some procedures move smoothly from scheduling to billing. Others generate layers of coordination, insurance authorizations, pre certifications, documentation requests, denials, appeals, patient follow-ups, uh, claims processing. That effort doesn't show up in a physician p and l as a line item.

It shows up as staff time, as payroll stress and administrative bandwidth being consumed in the background. I sat once with a scheduling supervisor who said, almost apologetically the doctor's cases take twice the coordination. It wasn't criticism. It was the reality. More complex cases, tougher payer mix, more moving parts, but the economic model treated scheduling costs as a flat percentage of revenue.

So leadership never saw the difference. The same pattern shows up in billing. Some physicians generate claims that sail through. Others generate claims that require repeated intervention. You all know which payers those are, um, and which TPT codes. Those are both, might collect similar dollars, but the operational load behind those dollars is dramatically different when shared services are allocated evenly.

Physicians whose work requires less support feel like they're subsidizing those who require more. Physicians whose work requires more support feel misunderstood because that effort isn't visible. Again, neither side is wrong. The system just isn't capturing the full picture. Once leaders acknowledge that hidden labor exists and begin aligning those cost drivers with workload drivers, conversations become less emotional and more analytical.

Now when I say aligning the cost drivers and, and workload drivers, this really means, uh, adjusting the way your your allocation process works. And that's where a productive leadership really lives. Facilities are another area where the economic story can drift from reality. Two surgeons might generate similar collections, but place very different demands on physical infrastructure.

Of the practice, longer procedures, specialized equipment, extended room turnover, and higher staffing requirements all increase the cost footprint, uh, of certain cases. Yet those differences often get pooled into a single facility cost bucket. Now, we could see this a lot of times maybe in booked days that physicians are having in a specific office block time.

I've seen situations where. Efficient surgeons with shorter procedures effectively subsidize longer resource heavy cases without realizing it. On paper, everyone shared facility cost evenly. In practice, utilization was far from even. This isn't about efficiency versus inefficiency. Many complex procedures are essential to the practices mission and reputation.

The issue is visibility. Not value judgment. If leadership can't see how facility capacity is being consumed within the allocation model, it becomes difficult to plan for growth. You may invest in ex in expansion without understanding where bottlenecks actually exist or hesitate to grow because profitability signals are unclear.

Where are patients coming from and, and which facilities are, are leveraging, uh, are being leveraged for those uh, cases. When facility costs start following usage patterns instead of averages, leaders gain a clear picture of which service lines create strain and which create opportunity. That Clarity supports smarter scheduling decisions, investment planning and recruitment strategy, all which can be driven from data within your accounting system if it has it.

And just as importantly, it reassures physicians that their economic story reflects the reality of their work. Most practices start with a single overhead bucket because simplicity seems safe. It feels safe. All shared costs go in, everything. A consistent rule distributes them out. It's easy to maintain and easy to explain, at least in the early stages of growth.

But as complexity increases, you're adding more physicians, adding more offices, adding more service lines, acquiring other organizations. That simplicity. Becomes distortion when every type of cost follows the same allocation logic, leadership loses the ability to see what's actually driving overhead changes.

Administrative leadership costs behave differently than facility costs. Billing behaves differently than it Staffing behaves differently than rent. Pooling everything together removes the signals. Leaders need to manage the organization intelligently. Physicians feel this as confusion, overhead moves, but the explanation sounds generic, costs went up, volume changed.

It's just the formula. Those explanations they don't satisfy people who are used to precise and cause and effect relationships in their clinical work. I've watched meetings spiral simply because nobody could articulate why overhead shifted from a specific physician without a clear narrative.

Suspicion fills the gap. Breaking the overhead bucket into meaningful components doesn't eliminate complexity. It reveals it. And once complexity is visible. Leaders can manage it. The goal isn't to create a hyper detailed system here that overwhelms everyone. It's to move from a instrument to a lens that shows where the pressure actually is high producing surgeons.

Interact with the system more than anyone else. They generate more cases, more clinic visits, more scheduling activity, more staff coordination. That exposure makes them the first to notice where the system struggles. When something feels off economically, they're usually detecting a structural issue.

Before leadership sees it in reports, but because they're speaking from personal experience, their observations can sound like complaints instead of diagnostics, smart leaders learn to treat those concerns as early warning signs. If your busiest surgeons feel misaligned with the economic story, it's worth investigating whether the system is translating activity.

Into cost. Cost accurately. Ignoring those signals can allow small distortions to grow into major trust issues. Addressing them early demonstrates that leadership is responsive and proactive, which is gonna strengthen your relationships even before the model improves. Or you implement a different system that truly delivers visibility and provides a framework for trust.

Most allocation models are built for the practice you used to be, not the practice you've become, and even more importantly, the one you want to become when the group was smaller with fewer locations, fewer physicians, and a more uniform activity. Simple wor simple rules worked. Well enough then growth happened.

New surgeons joined with different practice styles, new compensation arrangements, new locations opened with different patient demographics and ancillary services. Expanded payer mix has shifted. Maybe even your operational complexity increased, but the economic framework stayed the same. The allocation framework, the way you close the books, at the end of the every month, the way the reporting gets delivered to your physicians and physician owners.

At first the mismatch is subtle. Then it becomes noticeable. Eventually it becomes a source of tension, and unfortunately it can become and really transfer into screaming matches. I've seen groups where the model. Hadn't been meaningfully revisited in a decade, not because leaders were negligent, because everyone was busy running the practice, right, working in the practice and not on the practice.

Updating the system always felt like something to tackle later, but later eventually arrives in the form of distrust. Leadership's responsibility is to periodically ask whether the structure. It's truly guiding decisions still, uh, that reflect reality systems don't age gracefully on their own. When leaders treat the model as an evolution, as part of the growth strategy instead of a reactive fix, you're gonna find that you're staying ahead of the friction instead of chasing it.

One of the most disorienting moments. For leadership and physician owners, uh, CFOs is when the busiest surgeon in the group appears to be the least profitable on paper. And, and maybe this is you if you're a physician owner watching this. I've seen this happen more than once. A physician who is booked solid.

Generating significant collections, driving case volume, driving what seems to be growth and mentoring younger sergeants, and yet their p and l shows thin margins compared to peers. Now at a glance, leaders assume something must be wrong with their efficiency or maybe the coding or the case mix. The surgeon assumes they're being penalized.

And you know, the finance team, it's the model. It's working as designed. What's actually happening is that operational load is being absorbed but not recognized. High volume surgeons pull disproportionately. On scheduling, nursing coordination, billing complexity, equipment usage, and administrative oversight.

Maybe even it, maybe they use different software. Those costs accumulate in shared pools and then get distributed, and they're distributed using rules that don't align with their actual usage. So. What we're left with is an economic footprint of that surgeon's activity, which is spread across the organization while the report attributes a large share of the cost back to them.

So I, I re and, and I've seen a group where operational leaders privately said if he slowed down, the entire system would relax. That's the kind of impact that never shows up in standard reporting when leadership sees that disconnect clearly. The conversation shifts from questioning the surgeon to questioning the model, and that's a healthier place to be.

It's an objective place to be, not subjective, because models can be redesigned, systems can be improved, new systems can be implemented to solve a lot of these issues. Relationships are much harder to repair once trust erodes. The goal isn't to make superstars look good on paper. It's to make the paper reflect reality.

So physician owners, CFOs and controllers can make decisions without second guessing the signals when tension builds around compensation. It's tempting to frame it as a personality issue or a people issue. You know, this partner is sensitive. This partner is always focused on money, or finance is too rigid, the accountants are too rigid.

Maybe we are okay. Those explanations feel convenient because they avoid confronting the structure underneath the problem. In most cases, the conflict isn't coming from personality. It's coming from the misalignment between how the practice operates and how the economics are represented. Systems designed for a smaller, simpler organization rarely hold up once the practice grows.

What worked when everyone had similar schedules, similar case mixes and similar support, and it, it stops working when the variation increases. And especially now in this world where we have such amazing technology coming out, you know, something new coming out every week, you have to be at the front of your game looking at the technology in a way that is gonna help you scale and help you eliminate some of those problems.

And the sad thing is if you, if the last time you up updated your systems was years ago, you're still using the same tool you used five, 10 years ago. Odds are that probably is. The source of a lot of your contention, a lot of your issues, the danger is that leaders start managing symptoms instead of causes.

They smooth over disagreements, tweak compensation formulas or add one-off adjustments to keep the piece. We'll just change it this, this quarter, this, this half year, this year. We'll get to it next year. Those moves by time they do. But they don't rebuild trust. In fact, they often make the system feel more arbitrary because outcomes change without a clear explanation, get that, we'll just change it.

But we really didn't understand why it was wrong or why we feel the way we do. Strong leadership, strong systems, strong processes requires stepping back and asking a harder question. Does our system still reflect reality? Or are we forcing reality to fit the system? Once we can acknowledge that it's a design issue, not a people issue, the conversation becomes constructive.

You can redesign structures, you can't redesign personalities, and that shift alone can calm a group that's been stuck in defensive mode for months. Most compensation debates focus on the formula. At the end of the process, they focus on the Excel spreadsheet that you might be leveraging, but compensation is just the final output of a much larger system.

Revenue attribution, cost allocation, shared service distributions, facility utilization, staffing patterns. All of these feed into the number physicians ultimately see on their statements. Those inputs are distorted or don't include what we, what I just said. No compensation formula can produce a result.

That feels fair. It's like trying to adjust the thermostat when the real problem is insulation. You might get temporary relief, but the underlying imbalance remains. Groups can redesign their compensation plans. And I, I've seen some that have multiple times without addressing allocation logic underneath each revision generated new debates because the inputs were still misaligned with reality. Now, if that's happening, you have to question who in the seat is responsible for that?

And. Who should be involved in that process? I mean, that, that's what it boils down to. There are so many different ways to accomplish allocation. Splits. Splits, but it's a difficult thing to put them into practice and get a model that truly reflects reality. Once you've been able to, once you can correct how costs follow activity, the existing compensation structure.

It's gonna start to work without requiring major changes. That's an important insight for physician owners. You don't necessarily need a new comp plan. You may need a clear economic foundation underneath it. When inputs reflect operational truth, outputs become defensible. Physicians may not love every outcome, but at least now they understand it and understanding is gonna reduce friction.

If you are a physician owner listening to this and thinking, okay, but where do we even start? The answer is simple and it's simpler than you might expect. Start where the heat is. Which cost pools generate the most debate? Which offices? Who is it? Physician, assistant support, scheduling, billing, workload.

Facility usage. It costs software allocations, even, you know, administrative leadership cost allocations. There's usually a short list. Everyone knows it. You don't need to analyze everything at once, either target the area is causing the most tension because that's where trust erosion is happening. Bring operations and finance together for this conversation.

Include your controller, include your CFO because they're gonna be the ones in the position to model something out that is gonna fix this problem. So they are your best friend. Operations understands how workflows your finance and accounting team understands how costs move. When we can marry those perspectives, you get a clear picture than.

Either side alone, avoid the temptation to build a perfect model immediately. Perfection is fragile. What you want is a logic that is explainable, consistent and aligned with reality. I often tell, uh, clients that clarity beats precision. A model that's 80% accurate and understandable will generate more trust than one that's 95% accurate, but.

Unexplainable start small test adjustments. Model out what a compensation, uh, plan would look like in the current state versus the the tomorrow state. Observe how meeting dynamics change then expand. The goal is not mathematical elegance. The goal is leadership alignment. You don't need a massive overhaul to see relief either.

In many practices, two or three targeted adjustments dramatically reduce conflict tracking, PA utilization more accurately. For instance, letting certain shared SARS follow workload indicators, segmenting facility costs by usage, usage patterns. These changes don't eliminate overhead. They make overhead Make sense?

So why? Because it addresses the area where physicians feel the disconnect most intensely. When leaders demonstrate that the system can evolve, trust begins to rebuild. Physicians see that concerns lead to action instead of dismissal. If we can get all these issues on the table, we can begin to work through them and assign to-dos to everyone.

Momentum matters here. Early wins will create confidence that alignment truly is achievable. So consistency is one of the most underrated trust builders in multi physician owned practices. Consistency if allocation logic changes frequently, even for good reasons, physicians assume outcomes are being manipulated.

I mean. It seems like it's human nature if it just keeps changing and changing and changing. Why? Stability allows people to interpret changes in performance instead of questioning the rules. Documenting the logic matters too. When physicians can see the principles behind the model and know those principles will be applied consistently, anxiety's gonna drop, and heated debates are gonna become a little less cold.

Heated debates are gonna become colder. I'll say it that way. I've watched groups calm down simply because they stopped making quiet adjustments behind the scenes. Transparency can go a long way, and transparency will lead to a reduction in suspicion. Predictability. Allows leaders to plan predictability is what is gonna allow you to build trust with physicians, and it's gonna allow physicians to understand the cause.

In effect, it turns the p and l from a surprise generator into a navigation tool. You don't need a perfect system. You need one that behaves the same way month after month. Unless leadership intentionally changes it, that stability is gonna give physicians confidence. It is gonna give them confidence that the effort they're they're driving and the outcomes they're delivering, that it's all connected.

And once that connection feels real, the conversation shifts from is this fair to how do we improve from here? That's the moment where. The entire team is gonna regain control of the narrative, and the organization can focus now on growth instead of friction and debate. This is usually the point where groups realize they need an outside perspective because internal teams are too close to the system to redesign it objectively.

When the economic story starts matching operational reality, something subtle but powerful happens inside the group, physicians stop interrogating the numbers and start using them. The tone of meeting shifts almost immediately. Instead of that can't be right. Help me understand what changed.

That's a completely different posture, right? Talk me through this. Help me understand it. One is defensive, the other is curious. I've seen groups go from spending the first 45 minutes of a meeting debating overhead to spending that time discussing staffing strategy, service line growth, and recruiting decisions.

Same people, same personalities, same pressures, just a system that finally is reflective of how that work actually flowed through from the practice to the financial statements. Trust doesn't mean every physician suddenly loves every outcome either. It means the outcomes. Feel explainable. Physicians are trained to work inside complex systems.

They can accept variability if they understand the drivers behind it, and that's our duty as, uh, CFOs and controllers to help explain it to help drive clarity. Once the story makes sense, leaders regain one of the most valuable tools. That's the ability to make decisions without re-litigating the past every month.

And that's what, and that's when growth becomes possible again, because growth requires alignment. Alignment requires trust, and trust requires a system that doesn't distort reality. So if you want a quick test of this, ask yourself this. Do your physician p and Ls spark a strategy conversation or a fairness debate?

Another great question. Do your physicians even receive profit and loss statements? Can they see their own profit and loss statement? You know, how they fit into the bigger picture? That answer tells you everything about whether your system is helping leadership or slowing it down. One cost that almost never shows up in the p and l is leadership time.

When physician owners, CFOs and administrators spend hours debating the same allocation logic month after month, that's just frustrating. It's. It's not just frustrating, it's expensive. Every hour spent defending the model is an hour not spent. Improving operations, expanding services, recruiting talent, or answering that question that is gonna drive two x three x five x 10 x movement and top line revenue or cost reduction, slow decisions, create ripple FL effects.

Hiring gets delayed. Equipment purchases, stall expansion plans sit on hold. Competitors are gonna move faster. The practice becomes reactive instead of strategic. I've seen groups with enormous clinical capacity just stuck in neutral simply because they couldn't align on the economics.

Nobody wanted to commit to a direction while the numbers felt questionable. When trust is restored. Decision speed increases dramatically. Leaders stop hedging. They move forward with confidence because they believe the the signals they're seeing. Speed is a competitive advantage in healthcare right now.

It truly is. The groups that align quickly, adapt faster, they recruit better and capture growth opportunities before others even finish debating them. So this isn't just about physician satisfaction or fairness, it's about protecting leadership capacity of your organization. If your meetings feel like you're spinning instead of advancing the issue may not be the people in the room.

It may be the system they're relying on to guide them

when economic clarity improves, and I promise. We're gonna get to a big point here. When the economic clarity improves growth stops feeling risky. Leaders can see which service lines genuinely create value, and which ones just create volume. Recruiting decisions become grounded in data instead of intuition.

Investments in new locations or equipment, um, feel deliberate instead of hopeful, right? Because you've got data. Driving those decisions. Physician relationships improve too when compensation feels tied to reality. Partnership, conversations become forward looking instead of backward looking. I've worked with a group that delayed adding new sergeants for almost a couple of years because they couldn't agree on how the economics would play out, how the compensation model should be structured.

Once their allocation model evolved, the conversation flipped from, can we afford this? To how quickly can we support this? Now, that's amazing. Growth requires a shared understanding of reality. Without that, every strategic move feels like a gamble. And the irony is that most groups already have the operational strength to do this.

What they lack is a financial lens. A financial system, and a partner that can help them. Get the system to reflect that strength accurately. Alignment doesn't just solve the tension, it's gonna unlock momentum that you've never seen before. So here's a pressure test that you can run this month. Ask your finance team to explain the top five overhead drivers in plain language.

I'm sorry, my friends. Uh, all of you that are accountants and CFOs and responsible for this, this is gonna be a tough one. As I know, if you don't have the right systems in place, this is something that's gonna probably take you a while to do. That's a great opportunity because there are systems out there that can help you answer those questions very quickly.

Not in accounting language, either. Operational language, ask what activity causes those costs to move and weather that logic still reflects how your practice actually runs today. Then ask a physician owner a simple question. Does this story match what your experience is day to day? You're not asking whether they like the outcome, either.

You're asking them whether it makes sense. Is it believable? Hey, cash collections are up and it's because I'm seeing X, Y, Z. Does that make sense? I'm seeing adjustments go up as well. Contractual adjustments, and it looks like it's driven by these specific CPT codes and these specific payers, as that makes sense.

If those two perspectives don't line up, you found your gap. Next, look at your last three leadership meetings. How much time was spent debating numbers versus making decisions? If the ratio is skewed toward debate, the system is costing you momentum. This isn't about perfection. No model captures reality completely.

It's about whether your system is directionally accurate and stable enough to support leadership practices that run this pressure test often discover that the friction they've been attributing to personalities is actually, it's just structural and structural problems can be fixed. So if this episode resonated with you, it's probably because you felt this tension inside your practice.

High producing surgeons and physician owners working harder, but feeling disconnected from the outcome. Finance and accounting teams stuck defending models. They didn't design administrators trying to hold alignment together while decisions slow down. Here's the most important point I want you to leave here with today.

This is solvable. Rebuilding trust around physician economics doesn't require tearing down your compensation model or creating an academic allocation system. Nobody can maintain. It requires leadership, deciding that the story, the numbers tell must match the reality of how the practice operates. Plain and simple.

At Campbell Technology Advisors, this is exactly the work we do with orthopedic groups and multi physician owner owned practices, uh, across the country. We help physician owners, CFOs and leadership teams redesign the economic framework underneath their reporting, so it reflects real activity. Pa utilization, shared services, facility, demand, hours, blocks, service line dynamics, then we implement it in a way that's sustainable, not a one-time project, a system your team can run month after month without chaos.

One that is driven by advancements that are being made in, uh, ai. I mean, we're talking AI automation with, uh, AP bill. Your accounts payable function, uh, the revenue integration with your EMR, the dynamic allocations that automate the allocations and, uh, put into practice the allocations that are gonna reflect reality.

The outcome isn't just better reports, it's calmer meetings, faster decisions, restore trust among partners, and a clear pathway to growth. If you're ready to stop guessing and start leading with confidence, reach out. We can help you design and implement a system that brings your physicians back into alignment and positions your practice for the next stage of growth.

Because compensation should reflect economics now, politics. So thanks for listening to Beyond the Numbers. I'm Randy Kardas. I'll see you next time where we go beyond the spreadsheets, beyond the chaos, and of course, beyond the numbers.