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Becker’s Healthcare Podcast
Private Practice, Academics, and the Future of Spine Surgery with Alan H. Daniels, MD
00:15:01
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- [00:00]
A
This is Carly Beam with the Becker Spine and Orthopedics Podcast. I'm thrilled to be joined today by Dr. Alan Daniels. Dr. Daniels, thank you for joining us.
- [00:09]
B
Thanks for having me.
- [00:10]
A
So, before we dive into our questions, I wanted you to please introduce yourself and share a bit more about your background.
- [00:17]
B
Yeah, so I'm an orthopedic spine surgeon in Providence, Rhode island, at Brown University. I did my training here and stayed on. And one of the main reasons was we have an organization called University Orthopedics, which is a private practice, the large orthopedic practice of 70 surgeons that basically is center that owns our own real estate. We have ancillary services, and we have facilities all over the region. And it's just. Has been a very rewarding way to practice in that I get to have a very fruitful, I'll say, private practice, while I also do a lot of academics, teach residents, fellows, and work very closely with the university. So it's really a perfect mix for me, definitely.
- [01:04]
A
And I'd love to hear, you know, what are the biggest advantages you've been seeing, both working from the private practice perspective and then also in the academic setting?
- [01:14]
B
Well, you really nailed it on the head and that there are advantages to each, and that's why it's so nice being in a private academic environment. The advantages of private practice are that we have a lot of autonomy, you know, whether it comes to simple things like hiring and firing staff or figuring out how to allocate funds or even funding research. When you're in private practice, there's less administrative challenges and oversight, and it allows people, especially entrepreneurial people or people with other interests, to be able to continue working forward in your private practice and. And build it in the way that you see fit. So, you know, we. We all have people that are our bosses, whether it be my chair or the president of the organization. But when you're in private practice, there tends to be more ability to. To, I'll say, form the practice you want to have, whether it being in the days of the week that you're seeing or operating your travel schedule, your vacation schedule. It's just a lot of freedom. And that pairs nicely with the advantages of academics, which are to work with residents and fellows is really, I would say, the most rewarding thing that I do. Teaching is a lot of fun. It's invigorating to work with young people doing research is just a blast. It's. You feel like you're really forward, you know, helping the field move forward. And so to basically Be able to pair those advantages together of private practice and academics is really a gift.
- [02:43]
A
And when you think about the, you know, the, the young residents, fellows, the med students, future of spine surgery, are you optimistic, nervous? What are some of big lessons that you're preparing them for?
- [02:59]
B
Well, I'm an eternal optimist. I'm completely optimistic. I think despite the challenges of modern health care, there are patients who will need their spines and orthopedic problems taken care of forever. And so the world needs us. And despite some recent news that, oh, maybe robots will be replacing surgeons, that just is not the case. We will be needed by society to help take care of people, and to do so is a true honor. And it's fun and it's exciting and the field continues to move quickly. And so I'm completely optimistic about spine. I think there are many challenges that we'll all face that I'm sure we'll talk about today. But our job is just to figure out how to navigate them, to figure out how to advocate for our specialty and for medicine and for our patients in general and, and to just figure out how to take the best care of patients we can in this system that we were dealt.
- [03:52]
A
I like that. You're very a glass half full type of guy.
- [03:55]
B
Yes.
- [03:57]
A
And so, you know, you did mention headwinds. You know, especially from the private practice perspective. What are some of the biggest headwinds you're anticipating and how are you going to get ahead of them?
- [04:09]
B
I think the primary headwind that we all have to face is really reimbursement, and it's a little disappointing because inflation is obviously a problem in society as a whole. But to see Medicare reimbursement dropping paired with the fact that private payers tend to tie their reimbursement rates to Medicare, it is concerning. Now, again, I'm glass half full. We're going to find ways to continue to deliver care. We're going to find ways to be financially viable, but we have to run a business. That's the thing about private practice, is that I have employees who I give a raise to every year, of course, because they deserve it and they need it and they, they work very hard. But if, you know, reimbursement keeps getting cut by the insurance companies at some point, that is a problem because the money's got to come from somewhere. And so clearly, you know, we can find ancillary revenue streams and other ways to continue making sure to have a viable business. But that headwind itself is the one that's at the forefront of many of our minds that we really just have to keep a very close eye on it, carefully monitor it, and have, you know, short term and long term plans to deal with it. But the problem is, since so much of it is out of our control, you know, if the federal government were to cut reimbursement drastically, that's just a budget problem that happens immediately, that has to be resolved. Got it.
- [05:38]
A
And how are you thinking about then growing over the next 12 to 24 months?
- [05:45]
B
Growth is always challenging for me, for example, because I'm a very busy spine surgeon who's been busy for a number of years. So I can't just think about growing by doing more cases because that really can't be done. One interesting thing about a busy spine practice is you also can't just grow by seeing more patients because you have to be very careful, especially if you have a mature spine practice. If you see more patients, there will be more surgeries that come through and you won't have time to do them, at least not in a timely manner, at least in this country. We tend to try to give people surgery within a reasonable amount of time. Spine patients are in a lot of pain. If you tell them they have to wait three months or six months for surgery, that, I mean, it's just not compassionate to the patient, number one. And it may not be tenable to a practice. And so I think, at least in terms of our practice, we've thought about growth in a number of ways. Number one is that we have grown by hiring multiple young spine surgeons and then putting them out into nearby communities that have need. There's data that's been published multiple times that says the volume of spine surgery is directly correlated to the number of spine surgeons rather than the number of patients who need spine surgery. And so we've been careful to try not to just hire spine surgeons and put them in relatively saturated areas, but to find hospitals, hospital systems, and regions that really have deficient spine care. You know, the patients are currently having to travel long distances and to try to give them service right in their backyard. So for us, the growth, first is by hiring spine surgeons, second is by continuing to offer ancillary services to them, such as additional, you know, physical therapy services or other pain management services to help help them alleviate their pain through non surgical methods. And then lastly is through complexity of care. We have really prided ourselves at Brown on being a true tertiary or quaternary center for spine. We take care of any spine problem that exists, as complex as it can be, because a Lot of these community centers can't do that. And so to be able to take care of the most of the most complex problems is at least a way that I see. It's a different type of growth, but it is still growth nonetheless.
- [07:59]
A
It sounds like an absolute win win approach, bringing in these new surgeons and then putting them in these underserved areas. That's right, yeah. And then I wanted to pick your brain on. I know you're an expert in spinal deformity care and I was wondering what innovations you're most excited about in that area.
- [08:22]
B
Yeah, it is really exciting and let me tell you, it's very humbling because treating spinal deformity, when it goes well, it's incredibly life changing for the patients. It's amazingly smooth actually. These surgeries are invasive, but people can bounce back really quick. But when it doesn't go smoothly, they can be so disastrous with, you know, repeat and multiple surgeries, complex medical complications, revision surgery after revision surgery. And so what I see most exciting about spinal deformity, I would say three different things. The first would be using data and AI to select patients that are optimal for surgery, figuring out what their optimization plans are and then providing the most optimal treatment. It's hard to do because there's such variability in the way we treat spine patients. There's one surgeon who might do anterior approaches or another one that does lateral approaches. Someone else says, I develop posterior approaches. And someone surgeon might say I'll do a short fusion for this patient while another surgeon would do a long fusion. And anytime you see that much variability, you have a problem on your hands. It means you probably don't have optimized data or delivery. I think over time, through improved data initiatives and AI, we're going to be delivering better evidence based care. The next thing is specialized teams. It is absolutely mandatory that you have a team that's adept at treating spinal deformity. Because I've seen people out in the community do these fairly complex cases. The surgeon's very skilled and the patient starts having a problem and some staff member, someone else doesn't really know what to look out for. And then a catastrophic complication ensues. So if you're going to do this kind of work, you need to have front desk staff and administrative staff, nursing staff, physical therapy, the or everybody who's used to treating this kind of thing. And that's why what we've done at Brown and the Miriam is built a very highly skilled team of people who actually have an interest in this problem. You can't just have people who say like, oh yeah, yeah, I do orthopedics. That's not enough. It has to be people who know complex spine and spinal deformity. And then the last thing is alignment. We've done a lot of work in spinal alignment. We're making some great progress in terms of figuring out optimal alignment for patients. And there's some very exciting products coming out in the pipeline that will be specific patient implants for their alignment that I think will really continue to revolutionize complex spine and spine fusion care.
- [11:01]
A
So lots of moving parts it sounds like.
- [11:04]
B
Yep, definitely.
- [11:06]
A
Yeah. And then just last question for you, Dr. Daniels. Can you just go through three big trends that you're following closest in healthcare today?
- [11:16]
B
Absolutely. I think the first trend has to do with reimbursement, as we talked about, but is also closely tied to value based and outcome driven care. I think they're all wrapped in together now. We've been talking about value based and outcome driven care for a long time and it's not like it's just all going to be a wave and show up in the next six months or one year or two years, but it is coming especially in spine because poor outcomes are not sustainable. And somehow we as a field need to figure out how to help the insurance companies and help the payers with outcome driven care and value based care. And it's really hard because measuring outcomes is difficult. Centers like ours that take care of really complex spine problems, you know, we'll take patients from all over the region that have already had failed spine surgery. And the reality is though, patients don't always do well. And so if we are purely in an outcome driven care model and we take those really tough cases on, there may be payers who don't want to reimburse us well for that because our outcomes are poor. And so I think it's going to take some collaborative effort between spine specialists, practice hospital systems and the insurers to figure out what that really means for outcome based care. The second would be also something we briefly touched on, which is data integration and AI enabled decision support. Basically meaning that we just must use data better to help deliver more evidence based care because if we don't do it, that variability is what's going to kill us because it makes us look like we don't know what we're doing. And the people with poor outcomes can keep basically delivering that poor career, very high cost levels. And eventually as we know, the payers are going to look and say we're paying way too much. For spinal fusion and the patients are doing poorly, when in reality, if you look at the subset who are doing great, it's excellent care that's delivered at a very reasonable value. But I think we're going to need AI to do that. I think the, the last thing is probably just the sustainability of the workforce. And that's not just the spine surgeons and coming from both neurosurgery and orthopedics, it's really figuring out how to keep nursing staff, administrative staff, all the support staff basically engaged. And it's a challenge because as we know, the expense of keeping really high quality staff is high. You know, we've seen multiple union strikes from nurses here in our region and reasonably so I understand it, it's because they have to vouch for their own livelihoods. But I think figuring out how to have true team based models will be really important and we've had to fight that battle and we're continuing to regionally because everyone has a slightly different viewpoint of what's important. Meaning that the hospital just has to make sure there's nurses on every floor that can take care of every problem. When I'm laser focused on making sure my spinal deformity patient has a nurse that's highly specialized in spinal deformity and it works in relatively big hospitals. But as hospitals get smaller and smaller, of course it's harder because you can't have ultra subspecialized teams and small subspecialty, or, excuse me, small community hospitals. So I think that's a challenge that we are going to continue fighting and we'll look different in different communities.
- [14:48]
A
Well, Dr. Daniels, thank you so much for joining us today. It's a pleasure speaking with you and I hope to connect again. Don the line.
- [14:56]
B
I really appreciate it and thank you so much. Look forward to talking again at some point.