Life of Flow

Before you buy into an ASC, ask what you actually own—and who controls the decisions.

Dan Lieberman, MD joins Dr. Lucas Ferrer and Dr. Miguel Montero-Baker to unpack ambulatory surgery center ownership, the partners you choose and the agreements that shape your independence.

Dan trained in neurosurgery at UCSF, spent nearly two decades in solo practice and chaired the governing board of a physician-owned hospital. After essential tremor ended his operating career, his experience building ASCs became a new way to help physicians shape where and how they work.

Miguel brings the question many independent physicians hesitate to ask: after building a practice you control, why put your future in other people's hands? Dan's answer moves from the cost of taking a vacation to the financial model, exit arrangements and decisions physicians need to understand before signing.

In this conversation, Dan reveals:
⬛ Why owning a hospital made him rethink the environment in which he wanted to practice
⬛ How OBLs, ASCs and hospitals can serve different needs—and why patient selection comes first
⬛ Why owning your practice does not necessarily mean owning your time
⬛ What to ask about leaving a partnership before you agree to enter it
⬛ How to challenge a pro forma instead of treating its assumptions as promises
⬛ Why your ownership percentage does not tell the whole story about control
⬛ How the wrong partner can undermine an otherwise attractive business

The conversation ends with a practical checklist: understand the entity you would own, question the model, assess management, read the operating agreement and know your partners.

Which question would you insist on answering before buying into an ASC? Tell us in the comments.

TIMESTAMPS
00:00 Ownership, partners and control
00:57 Life of Flow intro
01:12 Welcome Dan Lieberman
02:10 From neurosurgery to ASC development
05:59 The microhospital question
21:00 OBLs, ASCs and choosing the setting
24:49 Medical necessity comes first
33:58 The trust question
37:02 Independence and the cost of time away
40:53 Ask how the partnership ends
45:56 Challenging the financial model
52:20 Governance and physician control
53:38 Pitfalls and choosing partners
55:58 Choosing an operator: the next conversation
1:00:16 Closing thoughts and farewell

FOLLOW DAN LIEBERMAN
LinkedIn: https://www.linkedin.com/in/dan-lieberman-md/
BestPracticeHealth / Phoenix Spine & Joint: https://bestpracticehealth.tv/about-us/

RESOURCES DISCUSSED
• Ambulatory surgery centers (ASCs), office-based labs (OBLs) and physician-owned hospitals
• Medicare reimbursement, ASC safe-harbor considerations and physician participation
• Project financial models, operating agreements, exit provisions and supermajority voting
• Essential tremor and the transition away from an operating career

LIFE OF FLOW
Hosted by Dr. Lucas Ferrer & Dr. Miguel Montero-Baker.
Website: https://lifeofflowpodcast.com
YouTube: https://www.youtube.com/@LifeofFlowPodcast
Spotify: https://open.spotify.com/show/5GMv47SJ0ePxbjtIb1GZ5U
Apple: https://podcasts.apple.com/us/podcast/life-of-flow/id1705596604
Partner with the show: info@lifeofflowpodcast.com

Connect with the hosts:
Lucas: https://www.linkedin.com/in/lucasferrermd/
Miguel: https://www.linkedin.com/in/miguel-montero-baker-a44354214/
Follow the show:
Instagram: https://www.instagram.com/lifeofflowpodcast/
X: https://x.com/vascularpodcast
LinkedIn: https://www.linkedin.com/company/lifeofflow

Cold-open music: “Funkorama” by Kevin MacLeod (incompetech.com), licensed under CC BY 4.0: https://creativecommons.org/licenses/by/4.0/
Source: https://incompetech.com/music/royalty-free/index.html?isrc=USUAN1100474
Excerpt edited, faded and mixed beneath dialogue.

Educational discussion, not individualized medical, legal or financial advice. The speakers describe their experiences and views; consult appropriate professionals about your own circumstances.

A child should not need another open operation because an implanted blood vessel cannot grow—and a vascular graft should not become a surface where clot and infection win.Dr. Arush Kalra is a physician, biomedical engineer, co-founder and chief scientific officer of PECA Labs. He left pediatric-urology training after an attending told him, “Don’t play the game; make the game.” At Carnegie Mellon, he turned toward biomedical engineering and a strict rule: better technology should preserve a surgeon’s familiar craft instead of forcing the surgeon to relearn it.The origin was personal. Kalra’s mother has Marfan syndrome and a bicuspid aortic valve. Her progressive aortic disease pushed him toward cardiovascular materials. PECA began with expandable ePTFE conduits intended to accommodate growth in children, then asked an adult-vascular question: can a familiar graft be redesigned to resist thrombosis, reduce hyperplasia, retain antibiotics and still feel intuitive?Kalra describes the graft as a sandwich: the surfaces govern how the body responds, while the center supplies strength, flexibility and compliance. His team changes the microstructure of a material surgeons already know and inspects every graft with scanning electron microscopy. He discusses encouraging preclinical comparisons, but these remain investigational results—not clinical promises.In this conversation, Dr. Arush Kalra reveals:⬛ Why he walked away from the identity his family and training had built for him⬛ How his mother’s cardiovascular disease redirected his career toward devices that can grow⬛ Why the best invention may preserve a surgeon’s technique while changing the material underneath it⬛ How microstructure, elasticity and compliance influence thrombosis and anastomotic hyperplasia⬛ Why PECA is exploring antibiotic retention rather than a drug layer that disappears quickly⬛ Why patient safety demands imagining the worst outcome, not merely the most likely oneTimestamps:05:24 Growing up above a neonatal hospital06:46 His mother’s Marfan syndrome and aortic disease07:43 “Don’t play the game—make the game”11:54 Searching for a cardiovascular solution12:22 The design rule: do not make surgeons relearn their craft14:07 A graft designed to grow with a child16:28 The origin of PECA Labs17:28 The obsession with clot formation19:41 Engineering the layers of ePTFE23:21 Why Arush praises the FDA process28:19 Scanning every graft with electron microscopy45:22 Why mistakes are the fastest education46:58 Starting with peripheral vascular disease48:23 Patient safety before commercial focus52:37 Anti-thrombogenic and antibiotic development paths53:24 Designing for repeated large-needle puncture55:21 The antibiotic strategy discussed with regulators56:59 The inventor as artist, scientist and surgeonFollow Dr. Arush Kalra:LinkedIn: https://www.linkedin.com/in/arush-kalra-b4aa4750/PECA Labs: https://www.pecalabs.com/Resources mentioned in this episode:🏢 PECA Labs — expandable, radiopaque, anti-thrombogenic and valved polymer platforms🧪 ePTFE, scanning electron microscopy and microstructured vascular graft design🏛 FDA 510(k) and De Novo pathways as discussed in the recordingLife of Flow is hosted by Dr. Lucas Ferrer & Dr. Miguel Montero-Baker.🌐 Website: https://lifeofflowpodcast.com▶ YouTube: https://www.youtube.com/@LifeofFlowPodcast🎧 Listen: Spotify https://open.spotify.com/show/5GMv47SJ0ePxbjtIb1GZ5U · Apple https://podcasts.apple.com/us/podcast/life-of-flow/id1705596604📩 Partner with the show: info@lifeofflowpodcast.comConnect with the hosts:Dr. Lucas Ferrer — [Lucas LinkedIn]Dr. Miguel Montero-Baker — https://www.linkedin.com/in/miguel-montero-baker-a44354214/Follow the show: Instagram https://www.instagram.com/lifeofflowpodcast/ · X https://x.com/vascularpodcast · LinkedIn https://www.linkedin.com/company/lifeofflowEducational only; never medical advice. Confirm product and regulatory timelines with PECA Labs.

Your title, schedule and reputation disappear in the jungle. What remains may be the first honest version of you that you have met in years.David Villanueva is the founder of Sukia Travel, a wildlife guide, adventure specialist and wilderness operator in Costa Rica’s Osa Peninsula. Michel Reijnen is a Dutch vascular surgeon who entered the expedition looking for a deeper experience of the jungle and returned with a different relationship to attention, identity and time.The Crucible is not a luxury retreat. Participants fly into Drake Bay, surrender familiar status, turn off their phones and travel roughly 100 kilometers through humidity, mud, rivers and steep terrain. They carry equipment, sleep in hammocks, journal, meditate and learn from indigenous guides, survival specialists, silence and the forest itself. David calls the underlying structure the FORGE protocol: leave the familiar frontier, meet a real ordeal, reflect and reframe the experience, cross a symbolic gateway, then return with a personal code.In this conversation, David and Michel reveal:⬛ Why a doctor, lawyer and executive become equals once everyone is exhausted and covered in mud⬛ How an ordeal can become empty adventure tourism unless reflection turns discomfort into meaning⬛ Why constant planning and replaying the past can quietly remove you from the life happening now⬛ What Michel discovered when he gave up his phone, camera and every connection to his ordinary identity⬛ How a 30-kilometer jungle day, river crossings and the “Witch Hill” expose the stories people use to survive⬛ Why fear should be recognized and processed rather than denied or muscled through⬛ How shared leadership, community and kincentricity challenge the Western obsession with the individualDo high performers need a place they cannot control to see what controls them?Timestamps:00:00 Pre-recording setup03:45 Welcome to Life of Flow07:22 David’s path into wildlife and adventure guiding08:48 Why the jungle strips away status09:46 The FORGE protocol for transformation12:36 Reflection, symbolism and the gateway16:09 What transformation actually means18:50 Inside the 10-Day Jungle Crucible23:02 The 30-kilometer day and the Witch Hill24:42 Roughly 100 kilometers through the jungle26:10 Kincentricity and the technology of cooperation43:34 The happiest and most frightening moments45:47 Getting lost without clean water48:29 Purpose, fear and leadership under pressure52:16 Michel’s edge in the jungle56:08 Who may need an experience like this58:07 How to find the Jungle Crucible60:28 Why David limits the number of expeditions61:32 Closing thoughts...Follow the guests:David Villanueva and the Jungle Crucible: https://sukiatravel.com/the-jungle-crucible/Michel Reijnen: https://www.linkedin.com/in/michel-reijnen-060991aa/Resources mentioned in this episode:🏢 Sukia Travel: https://sukiatravel.com/🌿 Costa Rica’s Osa Peninsula and Corcovado National Park📚 Carl Jung’s work on archetypes and the collective unconscious🧭 The FORGE protocol, journaling, meditation and symbolic rites of passage🤝 Kincentricity, community, shared leadership and reintegrationLife of Flow is hosted by Dr. Lucas Ferrer & Dr. Miguel Montero-Baker.🌐 Website: https://lifeofflowpodcast.com▶ YouTube: https://www.youtube.com/@LifeofFlowPodcast🎧 Listen: Spotify https://open.spotify.com/show/5GMv47SJ0ePxbjtIb1GZ5U · Apple https://podcasts.apple.com/us/podcast/life-of-flow/id1705596604📩 Partner with the show: info@lifeofflowpodcast.comConnect with the hosts:Dr. Lucas Ferrer — [Lucas LinkedIn]Dr. Miguel Montero-Baker — https://www.linkedin.com/in/miguel-montero-baker-a44354214/Follow the show: Instagram https://www.instagram.com/lifeofflowpodcast/ · X https://x.com/vascularpodcast · LinkedIn https://www.linkedin.com/company/lifeofflowEducational discussion only. The Jungle Crucible is physically and psychologically demanding, uses screening, and is not medical care or therapy.

Surgeons measure fistulas with precision—then send them into a dialysis-unit “black hole” where the same injury cycle starts again.Dr. Erin Moore is a Jacksonville vascular surgeon and former Navy physician who left roughly 15 years of military medicine for private-practice independence. There he owned high-volume dialysis access—about two to three hundred fistulas and grafts a year—and later became VP of clinical affairs around chair-side access-mapping software he names Veristra.This is not a war-story sequel. It is the systems problem behind failing dialysis access: thin tech training, on-the-job habits, high turnover, missing longitudinal stick history, area puncture as default, and a field that overbuilt stents and balloons while underbuilding the moment the needle hits the arm. Moore softens the old “micrometer vs ax” joke—staff are not trying to wreck access; they often lack tools, time, and information. His fix is mundane on purpose: photo + QR scale, mark arterial and venous sticks, color-age recent marks, and heat-map hotspots so the chair regains memory.In this conversation, Dr. Aaron Moore reveals:⬛ Why the unit becomes an information black hole after a surgical create⬛ How same-site puncture wears access toward pseudoaneurysm and failure⬛ Why rope-ladder is known to work—and still fails to become habit⬛ What a photo, QR scale, color-aged marks, and a fistula heat map change at the chair⬛ How pilot staff who only recorded points said they were still flying blind⬛ Why treating ~50% annual fistula patency as “OK” is a systems indictment⬛ What a 1973 patient-engineer already plotted on graph paper that centers still lackEducational discussion of workflow and systems—not individualized treatment advice. Early pilot signals are not universal outcome proof.The Dialysis Unit Is a Black Hole: Why Fistulas Keep Failing | Aaron MooreTimestamps:00:00 The dialysis access black hole00:45 Life of Flow intro00:59 Welcome back: entrepreneurship, not war stories01:47 Navy medicine to Jacksonville independence05:02 Owning dialysis access in private practice05:34 Micrometer surgery, missing chair-side tools09:31 Same cannulation paradigm since 196509:55 Why the dialysis unit feels like a black hole10:31 Overbuilt rescue tech, underbuilt point of care12:29 Area puncture vs rope-ladder reality13:44 Photograph, QR scale, mark every stick15:25 Heat maps that show where you’ve been18:26 From curious investor to operator25:24 Pilot lesson: recording without history is still blind32:33 Stop predicting pseudoaneurysms—prevent the pattern34:22 A 50% annual fistula patency bar37:28 The 1973 engineer who mapped every poke50:04 Pilot size, clustering trend, what to prove nextFollow the guest:LinkedIn: https://www.linkedin.com/in/vascularmdjaxProduct named in-episode: Veristra (dialysis access management software; spelling normalized from transcript variants)Resources mentioned:Rope-ladder vs area-puncture cannulation (discussed as established literature; no single paper titled on-air)Guest-stated CMS-scale U.S. dialysis burden and annual intervention needFDA breakthrough device pathway as narrated for their concept1973 dialysis reimbursement moment and the patient-engineer access logIf you operate or cannulate access, watch the black-hole segment, then the heat-map workflow, and ask where your system is still flying blind.Life of Flow is hosted by Dr. Lucas Ferrer & Dr. Miguel Montero-Baker.🌐 Website: https://lifeofflowpodcast.com▶ YouTube: https://www.youtube.com/@LifeofFlowPodcast🎧 Listen: Spotify https://open.spotify.com/show/5GMv47SJ0ePxbjtIb1GZ5U · Apple https://podcasts.apple.com/us/podcast/life-of-flow/id1705596604📩 Partner with the show: info@lifeofflowpodcast.comConnect with the hosts:Prepared for Life of Flow publication. Educational discussion only; not individualized medical advice. The core question is whether better chair-side memory can reduce repeated injury

WARNING: RVUs may measure a physician's activity, but they can keep doctors from seeing the real money their work creates. Hospitals know the value of every procedure. Most physicians never see the numbers.

Dr. Eric Smuclovisky is an interventional radiologist, former academic physician and independent physician-entrepreneur. After opening an OBL/ASC, he watched reimbursement cuts and negative media pressure threaten the model. He then found another route to autonomy: negotiating professional service agreements that allow physicians to work with hospitals without surrendering their independence as W-2 employees.

In this conversation, Dr. Eric Smuclovisky reveals:
⬛ Why physician fees collapsed while hospital facility fees expanded—and how that changed who controls American medicine
⬛ Why he calls RVUs “monopoly money,” and how doctors can begin discovering what is actually billed under their names
⬛ How the No Surprises Act, charge lists, payer contracts, and IDR expose the hidden economics behind a medical bill
⬛ Why the physician shortage may finally give doctors enough leverage to negotiate from strength

Eric explains why a hospital's charge list is its “dirty little black book.” Hospitals set prices then negotiate discounts with commercial payers; those deals are not simple multiples of Medicare. A summary of benefits might show an $80,000 charge, roughly $20,000 paid, and $1,000 owed by the patient. The gaps reveal the private contracts behind the bill. It matters.

Follow Dr. Eric Smuclovisky:
LinkedIn: https://www.linkedin.com/in/eric-smuclovisky-58206927b/

Resources mentioned in this episode:
🏢 Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/
🔗 Stark Law, CMS: https://www.cms.gov/medicare/regulations-guidance/physician-self-referral
🔗 No Surprises Act and independent dispute resolution, CMS: https://www.cms.gov/nosurprises
🔗 CMS Physician Fee Schedule and CPT reimbursement lookups

👤 Ross Perot, referenced during the discussion of RVU history

Life of Flow is hosted by Dr. Lucas Ferrer and Dr. Miguel Montero-Baker.
🌐 Website: https://lifeofflowpodcast.com
▶ YouTube: https://www.youtube.com/@LifeofFlowPodcast
🎧 Listen: Spotify https://open.spotify.com/show/5GMv47SJ0ePxbjtIb1GZ5U · Apple https://podcasts.apple.com/us/podcast/life-of-flow/id1705596604
📩 Partner with the show: info@lifeofflowpodcast.com

Connect with the hosts:
Dr. Lucas Ferrer — [Lucas LinkedIn]
Dr. Miguel Montero-Baker — https://www.linkedin.com/in/miguel-montero-baker-a44354214/

Follow Life of Flow:
Instagram: https://www.instagram.com/lifeofflowpodcast/
X: https://x.com/vascularpodcast
LinkedIn: https://www.linkedin.com/company/lifeofflow