Latest / Becker’s Healthcare Podcast / Alexander Vaccaro, MD, PhD, MBA, President of Rothman Orthopaedics

Transcript

Alexander Vaccaro, MD, PhD, MBA, President of Rothman Orthopaedics · Becker’s Healthcare Podcast

0:00
Hi, everyone, and
0:01
welcome to the Becker's
0:04
Spine and Orthopedic podcast.
0:06
I'm Sophie Ades, orthopedic reporter
0:09
with Becker's Healthcare.
0:11
And today, we're honored to be joined by
0:13
doctor
0:15
Alexander Vaccara, one of the most respected leaders
0:18
in spine surgery and orthopedic care.
0:21
He serves as president of Rothman Orthopedics and
0:25
is the Richard h
0:27
Rothman professor and chairman of orthopedic surgery
0:31
as well as professor of neurosurgery
0:34
at Thomas Jefferson University.
0:37
Doctor Vaccaro's career spans
0:39
clinical excellence,
0:40
academic leadership, and health system strategy.
0:44
His work in spine trauma and research has
0:47
helped shape
0:48
modern spine care, earning the trust of surgeons,
0:52
institutions,
0:53
and patients around the world.
0:56
In this episode, we're gonna explore what lies
0:59
ahead for orthopedic and spine care in 2026
1:03
from innovation and workforce evolution to leadership lessons
1:07
and the strategic growth of one of the
1:09
nation's largest
1:11
orthopedic
1:12
platforms.
1:13
Doctor Vaccaro, we're so happy to have you.
1:17
So to start,
1:19
I'll give you the opportunity
1:20
to introduce yourself and also share a bit
1:23
about your role.
1:25
Sure. Sure. I am a professor of orthopedic
1:28
surgery and neurosurgery.
1:30
I'm the chairman of the department of orthopedic
1:32
surgery at Thomas Jefferson University and the Sydney
1:35
Kimmel Medical Center,
1:37
and I'm the president of the Rothman Institute.
1:40
And my role at Jefferson in terms of
1:42
my clinical responsibilities is that,
1:45
one of the many spine surgeons, and we
1:47
have a great bunch of guys here
1:50
that do research, we teach,
1:52
and we do spinal care. And we serve
1:55
the Southeastern Pennsylvania community, Northern Delaware,
1:59
Southern New Jersey,
2:01
and those that wanna travel far and near
2:03
to to have service to Rothman Institute. So
2:05
that that's my current role at the present
2:08
time. Mhmm. Awesome.
2:10
Well, with that, we'll we'll dive right into
2:13
it.
2:14
Obviously, we're coming upon a a new year
2:16
here. So as you look ahead to 2026,
2:20
can you talk a little bit about just
2:22
what's top of mind for you,
2:25
what some of those opportunities
2:27
and and headwinds that you're looking out for
2:29
are?
2:30
Sure. So
2:32
I think there's a battle
2:34
for
2:35
top notch orthopedic providers, and that battle is
2:38
between
2:39
private practice,
2:40
multispecialty
2:41
groups,
2:43
hospital systems, and private equity.
2:46
So our job is to get those that
2:48
are interested in being entrepreneurial,
2:51
not interested in an employed model,
2:54
who understands the concept of risk. I mean,
2:56
if you join a health care system today,
2:58
you basically join a risk free compensation model.
3:02
Risk free.
3:03
The more bricks you break, the more RVs
3:06
you generate, the more you get paid.
3:09
And I'm not sure that's in the best
3:11
interest of the patient or the best interest
3:13
of the provider
3:14
itself or the physician.
3:16
So we try to give doctors the opportunity
3:20
to be innovative in the care they provide,
3:23
to have the flexibility and autonomy they need,
3:26
and that's what represents
3:28
private practice. So that's my opportunity.
3:31
Another opportunity is the ability
3:34
outside of
3:35
a hospital employed system
3:37
to have ownership of passive income sources, I
3:40
mean, such as facilities,
3:42
ASCs, specialty hospitals,
3:45
ancillary lines. And there's so many different creative,
3:48
productive ancillary lines all the way up up
3:50
until concierge medicine that you can provide. And
3:53
these are things that the employee model really
3:55
does not allow the individual
3:57
surgeons to aid, leave the rewards of, or
4:00
be incentivized
4:01
by. So I think that's
4:03
something that we have to do.
4:05
Another one is we have to sort of
4:07
establish to make sure everyone works up to
4:09
whatever their productivity standards are. So have everyone
4:12
in our group work to the level of
4:14
their license. If you're a PA and you're
4:16
licensed to do certain things in my group,
4:18
you should be doing those things. You shouldn't
4:20
be relegated to a medical assistant. You shouldn't
4:22
be relegated to a
4:25
secretarial role. You should actually be out there
4:27
doing what you need to do, and we
4:29
try to maximize everyone's schedule. I mean, if
4:31
you if you wanna be part time teaching,
4:33
part time research, that's fine. But the times
4:35
that you have allocated to these roles, we
4:37
wanna make sure that you're efficient and you
4:39
get things done. And we have to make
4:41
it so you can be efficient.
4:43
And then the last opportunity, I think, is
4:45
really
4:46
taking advantage of
4:48
advanced technologies. Now I hate to say the
4:51
buzzword agentic AI, but that's the buzzword now
4:55
because I use it literally
4:57
multiple times every day in everything I use.
5:00
And not only in the business side
5:02
to decrease employment costs, but I also use
5:05
it in the operating room. I use robotics.
5:06
So we're using advanced technologies to not only
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make surgery
5:11
safer,
5:12
more accurate, more precise,
5:14
but more reproducible.
5:16
These are the put in education from wrongs
5:17
also. But also
5:19
in terms of our business, you know,
5:21
responding
5:22
when we get our
5:24
submissions for surgeries rejected by the insurance companies,
5:27
immediately responding, saying, you know, here's the information,
5:30
any type of appeal process,
5:32
making sure we follow
5:34
what the patients require in terms of the
5:37
different offices we have, make sure we're full,
5:39
make sure we're maximizing our staff. So that
5:42
is what I think is the best in
5:43
terms of our opportunities.
5:45
In terms of our headwinds,
5:47
that that's a challenging thing. The the biggest
5:49
problem we have as providers
5:51
is that we have to deal with prior
5:54
authorization by
5:56
those individuals
5:58
not educated in the fields that they oversee.
6:01
Those that do the prior authorizations
6:04
abiding by certain clinical practice guidelines that don't
6:07
really take in to consideration the individual patient.
6:10
And sometimes, you have to think out of
6:11
the box
6:12
because at times, it may lead to worse
6:14
patient care and things that are not in
6:16
the patient's interest.
6:17
And we're constantly being inundated by denials and
6:20
policy changes. You you the the recent insurance
6:23
companies that decided on their own to downcode
6:25
CPT codes from level four to level three,
6:28
these are the things that we have to
6:29
do. And we go through, you know, a
6:31
a periodic process, payer contract renewals,
6:34
and sort of letting the world know that
6:37
every day,
6:39
my
6:39
overhead costs go up. We have to deal
6:41
with inflation, and we have to deal with
6:43
the cost of capital,
6:44
salaries,
6:45
staffing. That doesn't get cheaper every year, so
6:48
it doesn't make any sense that reimbursement can
6:50
go down every year. So we have to
6:51
come up with some consistent,
6:53
methodology to make sure that both the insurance
6:55
company, the patient, the government, and the physician
6:58
are protected
6:59
in terms of,
7:00
maximizing
7:02
whatever,
7:02
limited dollars are available for everybody.
7:05
And then,
7:06
we have to look closely
7:08
at our partners. We we we have multiple
7:11
health care partners. If one of our health
7:13
care partners has a disagreement with insurance company
7:16
and decides at the last minute, I'm not
7:18
gonna take this particular insurance, what affects our
7:20
patients is private practice, so we have to
7:22
deal with
7:23
that. And then we have to deal with
7:24
the inflationary pressures that everyone has to deal
7:27
with at the present time. I mean, the
7:28
I mean, the cost of
7:30
goods are going up. Mhmm.
7:32
My secretary will support my nursing staff. My
7:35
medical assistant's going up. And how do I
7:37
provide adequate care
7:39
when every year due to congressional
7:42
mandates,
7:43
reimbursement goes down? It just doesn't make any
7:45
sense. So we have to fight that.
7:47
Yeah. Great points there. I think you you
7:50
mentioned a ton of what is on,
7:53
you know, leaders across the board's mind in
7:55
terms of orthopedic,
7:57
you know,
7:58
opportunities
7:59
in the next year and also the headwinds.
8:02
And I think
8:03
the first time we talked, I think you
8:05
did mention
8:06
that idea of prior authorization
8:08
and claims being denied,
8:11
because a lot of these insurance companies are
8:13
using AI,
8:15
and things like that. So we're definitely still
8:18
seeing that continue
8:19
to be,
8:20
a problem, and it's definitely something
8:23
that leaders like yourself are gonna have to
8:25
navigate into the new year.
8:28
I'm wondering, doctor Vaquero, from a clinical standpoint,
8:32
which innovations
8:34
or care models do you think
8:36
will meaningfully
8:37
shift how orthopedic care is delivered in 2026?
8:42
So if you look closely
8:45
at what we provide patients anywhere from more
8:47
surgical
8:49
skills to nonoperative care such as injections,
8:52
stem cells,
8:54
hyaluronic acid injections for knees, bracing,
8:58
If we as orthopedic surgeons can sort of
9:00
control that business aspect
9:03
and take it away from high cost vendors
9:07
and bring that in house, like, all the
9:09
different ancillors you see
9:10
that don't pose a direct conflict. Like, you
9:13
you never wanna provide an ancillary
9:15
where you can increase the cost of care.
9:17
If it's something that you have to prescribe
9:19
to a patient,
9:20
why can't we be
9:22
the owner of that business
9:24
so then we can not only dramatically drop
9:27
the cost,
9:28
but also provide what we think is best
9:29
in class? I'll give you an example.
9:31
When you order a brace from a hospital,
9:34
an orthotist, it may cost a thousand dollars,
9:35
and that patient may say, well, listen. Let
9:37
me go to Amazon online and get it
9:39
cheaper.
9:40
So creating orthopedic tours where you could say,
9:42
listen. We can we can do better than
9:43
that. We can drop we can be the
9:45
manufacturer
9:46
and the distributor, and we can provide that
9:49
service and use technologies
9:51
that may support that. Like, you you use
9:53
three d printing
9:54
to create things that we may need to
9:56
brace a patient, which be a a great
9:58
idea. So that that's an opportunity
10:01
that we can, you know, strive to decrease
10:04
the cost of care. I think another innovation
10:06
in the care model is introducing the concept
10:08
that the medical doctors came up with, and
10:10
that's concierge medicine.
10:12
I mean, it is so frustrating now
10:14
to guide someone into an integrated health care
10:17
system,
10:19
and why can't we make that easy for
10:20
MSK care? You know, just say that someone
10:23
comes in, we can organize their imaging studies.
10:26
We can organize their nonoperative care. We can
10:28
do their physical therapy. We can do their
10:29
injections,
10:30
and then we can take them to the
10:32
journey if they require surgery, make sure that
10:34
we have support for their family, maybe a
10:36
meal service, maybe transportation.
10:38
After that, we give them premium opportunities to
10:41
come in when they need to be seen
10:42
by someone and not to not to roll
10:44
their eyes and have a headache. I I
10:45
just spoke to one of my partners today
10:47
who presented Grand Rounds who who discussed his
10:50
journey after brain surgery, and he was
10:53
so frustrating
10:54
to see the surprise billing, this and that.
10:57
Why can't we facilitate that for the patient
10:59
for those patients that had the ability,
11:01
to pay extra so we can make their
11:03
lives so much more comfortable. So I think
11:04
that's those are the innovative things we can
11:07
do in terms of shifting the care model.
11:08
We've we've already moved to bundle payments. We
11:11
went through that exercise. We realized
11:13
what costs too much and what doesn't cost
11:15
too much, but bundle payments were really a
11:17
race to the bottom. And once you reach
11:18
the bottom of you can't squeeze any more
11:20
juice out of that orange. Now we're looking
11:23
for ways of saying, okay. This is the
11:24
bottom line cost, and those people that can
11:27
afford to pay more may have the ability
11:29
to have less frustration. They everyone gets the
11:31
same quality of care, but less frustrations in
11:34
terms of navigating that care.
11:36
Super important points there.
11:39
And it's a phrase that I often hear
11:41
talking to orthopedic surgeons like yourself is the
11:44
race to the bottom.
11:48
And, yeah, I mean, I think that,
11:51
obviously, the innovations that you just talked about
11:54
would be, you know, great, and I think
11:56
that
11:57
2026
11:58
is really gonna be the year of putting
12:00
those things to practice. Right? Everyone was excited
12:03
about AI and all this new technology and
12:05
stuff in
12:07
2025,
12:07
but now it's time to to get to
12:09
work.
12:10
So
12:11
super great stuff there.
12:13
Obviously, the orthopedic workforce is continuing to evolve
12:18
from surgeons
12:20
to APPs
12:21
to care teams.
12:23
What are you prioritizing,
12:26
in 2026
12:27
to support your teams and
12:29
really help them thrive?
12:31
Well, then that's a great question because I
12:33
think, really, as we expand our care, we
12:35
have to do it through APPs.
12:37
And they're such an important part of the
12:39
provider network. They interface with our patients. They
12:42
see patients in clinic. They have their own
12:44
office hours.
12:45
They they select those that may need to
12:48
experience
12:49
higher level of care, IEC,
12:51
a surgeon, so they're fantastic. And then a
12:53
a lot of physicians have APPs that come
12:55
to the operating room. Now I'm an academic
12:58
professor, so I don't have a PA in
13:00
my operating room. So every two months, I
13:03
have a different chief resident, and every three
13:06
months, I have a different spine fellow. So
13:08
I go through the same routine where I
13:10
have to teach them how to position a
13:12
patient, how to do this or that, how
13:14
to close the patient, stuff like that. If
13:16
you have an APP
13:17
or physiatrists that you work with, once they
13:20
learn
13:21
it and they they're loyal and they stick
13:23
with you for a long period of time,
13:24
it dramatically
13:26
decrease decreases your anxiety,
13:29
the headaches. You don't have to think twice
13:30
about it. It's like having a mirror image
13:32
of yourself in the Operating Room helping you
13:34
with all the procedures. So we have to
13:36
continue to get people motivated and train the
13:39
extenders. Now the extenders can also reach out
13:41
to geographic territories that we don't have the
13:44
ability to be in. So, again, having extenders
13:46
go out to
13:48
geographic regions that we wanna have our tentacles
13:50
in as the Rothman Institute and but have
13:52
them meet patients that want our care. And
13:54
if we need to speak to that patient
13:56
while they're seeing a PA, use telemedicine
13:58
and if they need a higher level of
14:00
care,
14:01
see us. So in order for us to
14:03
scale our operations,
14:05
we have to figure out what the ratio
14:06
of those providers are, ratios of
14:09
MAs,
14:10
PAs,
14:11
and physicians, and what supports a growing practice.
14:14
So we analyze
14:16
the days out to see a PA and
14:18
the days out to see a a surgeon,
14:20
and then we look at those that need
14:21
to see a surgeon. And if those days
14:23
go above a certain number, we say, okay.
14:25
We we need more PAs or we need
14:26
more surgeons. So it helps us build our
14:28
workforce appropriately, and it helps us build our
14:31
PA support.
14:32
We also have our PAs do things a
14:34
lot of the nonoperative care.
14:36
So we we as we build a strong
14:38
nonoperative physician force such as nonoperative sports medicine,
14:42
physiatrists,
14:43
and so forth, they need support also from
14:46
PAs to set patients up for injections and
14:48
so forth. And so we we really wanna
14:50
make sure we invest in those APPs,
14:53
so we can support our professional growth.
14:56
Yeah. I think I think that's such a
14:58
big topic too,
15:00
just across the board with orthopedics. I know
15:02
I've, again, talked to a lot of different
15:05
surgeons who have mentioned just the importance
15:08
of APPs to,
15:10
you know, your everyday
15:11
work.
15:13
So really great great points there.
15:16
You kind of got into this that Rothman
15:18
has sort of tentacles in different places, which
15:21
is a really fun way to put it,
15:23
but Rothman really does have such a broad
15:27
footprint.
15:29
What changes or investments
15:31
are you planning to make next year?
15:34
K. So first of all, I'm a big
15:36
supporter of organic growth. So let me tell
15:39
you what that is. So we, years ago,
15:42
began to associate with other practices. We brought
15:44
them into the Rothman Institute.
15:46
And I always say culture
15:48
trumps strategy any day of the week. Mhmm.
15:51
And I we train we train. I train
15:53
four spline fellows a year. We train 36
15:56
residents,
15:57
all the different specialties of fellows.
15:59
And my best partners are those that came
16:01
out of our
16:03
training program that know exactly how we think,
16:06
not only in the operating room, but how
16:08
we think in terms of a team. Mhmm.
16:11
And we have a great we're sort of
16:12
a high performing team. You have people that
16:14
get together. There's pseudo teams, good teams. There's
16:17
high functioning teams. So they watch how we
16:20
how we perform as a high functioning team,
16:22
and, plus, they respect their professors and their
16:24
teachers.
16:25
So we wanna invest in additional providers, number
16:27
one. Then we also wanna make sure that
16:29
we have the appropriate footprint
16:31
and make sure that we expand strategically
16:35
in the right areas. And, again,
16:37
focus on technologies and and forecasting reports and
16:41
and population growth and stuff like that and
16:42
use all the old tools available to say
16:44
where we have to have patients, where we
16:46
have to have providers grow. And then we
16:48
want to geographically expand. Now that as I
16:51
said, we grow a core market. But if
16:53
we decide to do
16:55
and get together with a group that has
16:56
a similar value systems to Rothman Institute, we
16:58
publish our mission statement. We publish our values.
17:01
We publish all that, and we make it
17:02
public what we plan to do. We're here
17:04
for not only clinical excellence, but teaching, research,
17:08
and education.
17:09
So we wanna make sure that we team
17:11
up with like minded people, but leave economies
17:13
local. So if we team up with a
17:15
group in Ohio, our job isn't to manage
17:17
the back office. Our our job is to
17:19
scale those resources that make their back office
17:22
effective,
17:23
but contracting state specific. So they're gonna have
17:25
different reimbursement models. They're gonna have different workman's
17:27
comp laws and stuff like that. We can't
17:29
get into the weeds with that. But we
17:30
can get into the weeds when it comes
17:32
to
17:33
how to scale, how to use the resources
17:36
that we have, how to negotiate insurance contracts,
17:38
how to use the expertise that we've gathered
17:40
over time. So I think those are the
17:42
things that, we have to do and invest
17:44
in the future. Mhmm. And technology, technology, technology
17:47
is where it's at. Mhmm.
17:49
Yep. Absolutely. I think, again, another common theme
17:53
is technology. And, again, I'm gonna say it
17:55
again,
17:56
but 2026
17:58
is really gonna be the time to get
18:00
to work,
18:01
and
18:02
use that technology,
18:04
like you've been sort of explaining, to really
18:07
thrive.
18:09
And I really like what you said too
18:11
just about culture and and culture really trumping
18:15
strategy at the end of the day, and
18:16
I think that's an important
18:18
mindset
18:19
to have not only in in your workspace,
18:22
but in any workspace.
18:24
Looking back now, we're gonna reflect a little
18:27
bit. Looking back now on on 2025,
18:30
what's one lesson or moment,
18:33
that surprised you or reshaped your thinking as
18:37
a leader?
18:39
Okay. And this is is this everyone's problem
18:41
in medicine today?
18:43
And that's how crazy
18:45
the malpractice
18:47
situation is around the country.
18:49
The nuclear verdicts
18:50
Mhmm. Taking care of professional athletes that make
18:53
$70,102
18:54
$100,000,000
18:56
and to
18:57
go out and to treat these individuals
18:59
with the best care you know how. And
19:01
then if something goes wrong,
19:04
have that particular risk that can close down
19:06
an institution.
19:07
There has to be, at the federal level
19:09
and at the state level, target form that's
19:12
sober
19:13
that protects those that provide competent care. I'm
19:16
not talking about negligent care. I'm talking about
19:18
competent care. Because as you and I know,
19:21
sometimes,
19:22
actions are brought against physicians that do the
19:24
right thing, but the patient may have a
19:26
bad outcome. So we have to protect those
19:27
doctors, and we can't leave it up to
19:29
the whim
19:30
of those that may not be educated in
19:33
understanding
19:34
how that care was delivered and what is
19:35
the expected outcome. And I'm a big supporter
19:38
of medical courtrooms,
19:41
where these courtrooms are designed just like we
19:44
have it for,
19:45
arbitration for
19:47
brokerage legal matters and and other more specialized
19:49
courts,
19:50
we we have to really, really, really protect
19:53
the provider because there's only so much money
19:55
that can go around. And if you on
19:57
top of the fact that you're getting your
19:59
reimbursement cut
20:01
and you have to do more with less,
20:02
and then on top of that, your malpractice
20:04
cost goes up, and then there's a nuclear
20:06
verdict I'm only focused on when there isn't
20:09
negligence
20:10
and there's a verdict against you. That can
20:12
really affect all the patients in the community
20:14
that require care, and then you have to
20:15
close-up shop. So we've seen that happen in
20:18
the high risk,
20:19
specialties, and we have to protect against that.
20:21
And I I think medical malpractice is all
20:23
political.
20:24
I say everyone's supportive. If if there's harm,
20:27
patients have to be compensated in the setting
20:28
of negligence, but that's not what I'm talking
20:30
about. I'm talking about the egregious amount of
20:32
money that's spent on defensive medicine
20:35
and on settlements and verdicts when there's no
20:37
medical malpractice and there's no protection in some
20:39
states, and it doesn't make any sense to
20:42
me.
20:43
So we have to protect against the financial
20:45
risks. Another risk, again, in the legal realm
20:48
is
20:49
when people can come and,
20:52
drop ransom
20:54
viruses
20:55
on your health care system that hold you
20:57
hostage that happened at our health care system.
20:59
And there again, you you do the best
21:01
you can. You follow all the established rules
21:04
on, you know, don't don't click on
21:06
a email you don't recognize and do this
21:08
or that. But these these people are sophisticated,
21:11
and they use AI generated strategies to
21:14
infect your computer. And then all of a
21:16
sudden, you're locked out, and then you have
21:17
to pay the price. So we need we
21:18
need federal support for that and federal protection.
21:21
So, we basically need the federal government
21:24
to come out and help us and protect
21:26
those that care for people. We were decimated
21:30
in terms of a profession during the COVID
21:33
while we gave our time and and our
21:35
lives to take care of patients. So we
21:37
we need to have that type of support
21:38
from the government for these issues that we
21:40
have no control over.
21:42
Absolutely.
21:44
Again, super important
21:46
points there.
21:47
And, doctor Pacquero, this has been an incredibly
21:51
insightful
21:52
conversation, and I wanna thank you again for
21:54
sharing
21:55
your perspective and leadership insights
21:58
with us.
21:59
That is all we have today.
22:02
Pleasure to speak with you. Always a pleasure
22:05
to speak with you too.
22:06
Thank you so much for for joining us
22:09
and offering valuable insights into the future of
22:12
spine care,
22:13
orthopedic innovation, and physician leadership.