Latest / Becker’s Healthcare Podcast / Private Practice, Academics, and the Future of Spine Surgery with Alan H. Daniels, MD

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Private Practice, Academics, and the Future of Spine Surgery with Alan H. Daniels, MD · Becker’s Healthcare Podcast

• 0:00
  This is Carly Beam with Becker Spine and
• 0:02
  Orthopedics podcast. I'm thrilled to be joined today
• 0:04
  by doctor Alan Daniels. Doctor Daniels, thank you
• 0:07
  for joining us. Thanks for having me. So
• 0:10
  before we dive into our questions, I wanted
• 0:12
  you to just please introduce yourself and share
• 0:14
  a bit more about your background.
• 0:17
  Yeah. So I'm an orthopedic spine surgeon in
• 0:19
  Providence, Rhode Island at Brown University.
• 0:22
  I did my training here and and stayed
• 0:24
  on. And one of the main reasons was
• 0:26
  we have an organization called University Orthopedics, which
• 0:29
  is a private practice. It's a large orthopedic
• 0:31
  practice with 70 surgeons
• 0:33
  that basically is a
• 0:35
  center that owns,
• 0:37
  around real estate.
• 0:39
  We have ancillary services, and we have facilities
• 0:43
  all over the region. And it's just has
• 0:45
  been a very rewarding way to practice and
• 0:47
  that I get to,
• 0:50
  have a very
• 0:51
  fruitful,
• 0:52
  I'll say, private practice while I also
• 0:55
  do a lot of academics,
• 0:57
  teach residents, fellows, and work very closely with
• 0:59
  the university. So it's really a perfect mix
• 1:01
  for me.
• 1:03
  Definitely. And I'd love to hear, you know,
• 1:05
  what are the biggest advantages you've
• 1:08
  been seeing both working from a private practice
• 1:11
  perspective
• 1:11
  and then also in the academic setting?
• 1:15
  Well, you really nailed it on the head
• 1:17
  in that there are advantages to each, and
• 1:19
  that's why it's so nice being in a
• 1:20
  in a private academic environment.
• 1:23
  Mhmm. The advantages of private practice are that
• 1:25
  we have a lot of autonomy.
• 1:27
  You know, whether it comes to simple things
• 1:29
  like hiring and firing staff or figuring out
• 1:32
  how to allocate funds or even funding research,
• 1:35
  when you're in private practice, there's less,
• 1:39
  administrative challenges and oversight,
• 1:42
  and it allows
• 1:44
  people, especially entrepreneurial
• 1:45
  people or,
• 1:47
  people with other interest to be able to
• 1:49
  continue working forward in your private practice
• 1:51
  and build it in the way that you
• 1:53
  see fit. So, you know, we we all
• 1:55
  have people that are our bosses, whether it
• 1:57
  be my chair or the president of the
• 1:59
  of the organization.
• 2:01
  But when you're in private practice, there tends
• 2:03
  to be more ability to to, I'll say,
• 2:06
  form the practice you wanna have,
• 2:09
  whether it being in the days of the
• 2:10
  week that you're seeing or operating, your travel
• 2:12
  schedule,
• 2:13
  your vacation schedule. It's just a lot of
• 2:15
  freedom.
• 2:16
  And that pairs nicely with the advantages of
• 2:19
  academics, which are to work with residents and
• 2:21
  fellows is really, I would say, the most
• 2:23
  rewarding thing that I do. Teaching is a
• 2:25
  lot of fun. It's invigorating to work with
• 2:27
  young people.
• 2:29
  Doing research is just a blast. It's you
• 2:32
  feel like you're really for you know, helping
• 2:33
  the field move forward. And so,
• 2:36
  to basically be able to pair those advantages
• 2:38
  together of private practice and academics is is
• 2:40
  really a gift.
• 2:42
  I mean, thinking about the, you know, the
• 2:44
  the young residents,
• 2:45
  fellows, the med students, future of spine surgery.
• 2:49
  Are you
• 2:51
  optimistic,
• 2:52
  nervous?
• 2:53
  What are some of the big,
• 2:55
  lessons that you're preparing them for?
• 2:58
  Well, I'm an eternal optimist. I'm I'm completely
• 3:01
  optimistic. I think
• 3:02
  despite the challenges of modern health care,
• 3:06
  there are patients who will need their spines
• 3:08
  and orthopedic problems taken care of,
• 3:11
  forever.
• 3:12
  And so the world needs us. And despite
• 3:14
  some recent news that, oh, maybe robots will
• 3:17
  be replacing surgeons, that's just is not the
• 3:19
  case.
• 3:21
  We will be needed by society to help
• 3:23
  take care of people.
• 3:24
  And to do so is a true honor,
• 3:26
  and it's fun, and it's exciting, and the
• 3:28
  field continues to move quickly.
• 3:30
  And so I'm completely optimistic about spine. I
• 3:33
  think
• 3:34
  there are many challenges that we'll all face
• 3:36
  that I'm sure we'll talk about today, but
• 3:38
  our job is just to figure out how
• 3:40
  to navigate them, to figure out how to
• 3:42
  advocate for, you know, our specialty and for
• 3:44
  medicine and for our patients in general, and
• 3:47
  to just figure out how to take the
• 3:48
  best care of patients we can in the
• 3:50
  system that we were dealt.
• 3:52
  I like that. You're a very glass half
• 3:54
  full type of guy. Yes.
• 3:56
  And so then, you know, you did mention
• 3:58
  headwinds, you know, especially from the private practice
• 4:01
  perspective.
• 4:02
  What are some of the biggest headwinds you're
• 4:05
  anticipating, and how are you gonna get ahead
• 4:07
  of them?
• 4:09
  I think the primary headwind that we all
• 4:12
  have to face
• 4:14
  is really reimbursement. And and it's a little
• 4:16
  disappointing because
• 4:18
  inflation is obviously a problem in society as
• 4:21
  a whole, but to see Medicare reimbursement dropping
• 4:25
  paired with the fact that private payers tend
• 4:27
  to tie their reimbursement rates to Medicare,
• 4:30
  it's it is concerning. Now, again, I'm glass
• 4:33
  half full. We're gonna find ways
• 4:36
  to continue to deliver care. We're gonna find
• 4:38
  ways to be financially viable, but we have
• 4:40
  to run a business. That's the thing about
• 4:42
  private practice is that
• 4:44
  I have employees
• 4:45
  who I give a raise to every year,
• 4:47
  of course,
• 4:48
  because they deserve it and they need it
• 4:50
  and they they work very hard.
• 4:52
  But if, you know, reimbursement keeps getting cut
• 4:55
  by the insurance companies,
• 4:58
  at some point, that is a problem because
• 5:01
  the money's gotta come from somewhere. And so,
• 5:04
  clearly, you know, we can financially revenue streams
• 5:06
  and other ways to continue making sure to
• 5:08
  have a viable business, but
• 5:10
  that headwind itself
• 5:12
  is the one that's at the forefront of
• 5:14
  many of our minds, and we really just
• 5:16
  have to keep a very close eye on
• 5:17
  it,
• 5:18
  carefully monitor it, and have, you know, short
• 5:20
  term and long term plans to deal with
• 5:22
  it. But the problem is
• 5:24
  since so much of it is out of
• 5:26
  our control, you know, if the federal government
• 5:29
  were to cut reimbursement
• 5:31
  drastically,
• 5:32
  that's just a budget problem that happens immediately
• 5:35
  that has to be resolved.
• 5:37
  Got it. And, you know, how are you
• 5:38
  thinking about
• 5:40
  them growing over the next twelve to twenty
• 5:42
  four months?
• 5:44
  Growth is always challenging,
• 5:47
  for me, for example, because I'm a very
• 5:49
  busy spine surgeon who's been busy for a
• 5:51
  number of years.
• 5:52
  Mhmm. So I can't just think about growing
• 5:56
  by doing more cases because that really can't
• 5:58
  be done. And I one interesting thing about
• 6:01
  a busy spine practice is you also can't
• 6:03
  just grow by seeing more patients because
• 6:06
  you have to be very careful, especially if
• 6:08
  you have a mature spine practice. If you
• 6:10
  see more patients, there will be more surgeries
• 6:12
  that come through,
• 6:13
  and you won't have time to do them,
• 6:15
  at least not in a timely manner.
• 6:17
  At least in this country, we tend to
• 6:18
  try to give people surgery within a reasonable
• 6:21
  amount of time. Spine patients are in a
• 6:22
  lot of pain. If you tell them they
• 6:24
  have to wait three months or six months
• 6:26
  for surgery,
• 6:27
  that I mean, it's it's just not compassionate
• 6:30
  to the patient, number one, and it may
• 6:31
  not be tenable to a practice. And so
• 6:34
  I think
• 6:35
  at least in terms of our practice, we've
• 6:37
  thought about growth in a number of ways.
• 6:39
  Number one is that we have grown by
• 6:40
  hiring multiple young spine surgeons and then putting
• 6:43
  them out into,
• 6:45
  nearby communities that have need.
• 6:47
  There's data that's been published multiple times that
• 6:50
  says the volume of spine surgery
• 6:52
  is directly correlated to the number of spine
• 6:54
  surgeons rather than the number of patients who
• 6:56
  need spine surgery. And so we've been careful
• 6:58
  to try not to just hire spine surgeons
• 7:00
  and put them in relatively saturated areas, but
• 7:02
  to find
• 7:03
  hospitals,
• 7:04
  hospital systems, and regions
• 7:07
  that
• 7:08
  really have deficient spine care. You know, the
• 7:09
  patients are currently having to travel long distances
• 7:12
  and to try to give them service right
• 7:13
  in their backyard. So for us, the growth
• 7:16
  first is by hiring spine surgeons. Second is
• 7:18
  by continuing to offer
• 7:20
  ancillary services to them,
• 7:22
  such as additional, you know, physical therapy services
• 7:25
  or other pain management services to help help
• 7:27
  them alleviate their pain through nonsurgical methods.
• 7:31
  And then
• 7:32
  lastly is through complexity of care. We we
• 7:35
  have really prided ourselves at Brown on being
• 7:37
  a true tertiary or quaternary
• 7:40
  center for spine. We take care of any
• 7:41
  spine problem that exists as complex as it
• 7:44
  can be because a lot of these community
• 7:46
  centers can't do that. And so to be
• 7:48
  able to take care of the most of
• 7:50
  the most complex problems
• 7:52
  is at least a a way that I
• 7:53
  see,
• 7:55
  it's a different type of growth, but it
• 7:57
  is still growth nonetheless.
• 7:59
  Yeah. It sounds like an absolute,
• 8:00
  win win approach when you're bringing in these
• 8:03
  new surgeons and then putting them in these,
• 8:06
  underserved areas.
• 8:08
  That's right. Yeah. And then, you know, I
• 8:11
  wanted to pick your brain on just yeah.
• 8:12
  I know you're an expert in spinal deformity
• 8:15
  care, and I was wondering what innovations
• 8:18
  you're most excited about in that area.
• 8:21
  Yeah. It is really exciting. And it let
• 8:23
  me tell you, it's very humbling because treating
• 8:25
  spinal deformity,
• 8:26
  when it goes well, it's incredibly life changing
• 8:29
  for the patients.
• 8:30
  It's amazingly smooth, actually. These surgeries are invasive,
• 8:33
  but people can bounce back really quick. Mhmm.
• 8:36
  But when it doesn't go smoothly, they can
• 8:38
  be so disastrous with,
• 8:40
  you know, repeat and multiple surgeries, complex medical
• 8:44
  complications,
• 8:45
  revision surgery after revision surgery. And so
• 8:49
  what what I see most exciting about
• 8:51
  spinal deformity, I would say three different things.
• 8:54
  The first would be using data and AI
• 8:58
  to select patients,
• 9:01
  that are optimal for surgery,
• 9:03
  figuring out what their optimization
• 9:05
  plans are, and then providing the most optimal
• 9:07
  treatment.
• 9:08
  It's hard to do because
• 9:10
  there's such variability in the way we treat
• 9:12
  spine patients. There's one surgeon who might do
• 9:14
  anterior approaches or another one that does lateral
• 9:17
  approaches. Someone else says I do well posterior
• 9:19
  approaches, and someone
• 9:20
  surgeon might say I'll do a short fusion
• 9:22
  for this patient while another surgeon would do
• 9:24
  a long fusion. And anytime you see that
• 9:26
  much variability,
• 9:27
  you have a problem on your hands. It
• 9:29
  means you probably don't have
• 9:31
  optimized data or delivery.
• 9:33
  And so I think over time through improved,
• 9:37
  data initiatives and AI, we're going to be
• 9:40
  delivering better evidence based care.
• 9:43
  Mhmm. The next thing is specialized teams.
• 9:46
  It is absolutely
• 9:48
  mandatory that you have a team that's adept
• 9:50
  to treating spinal deformity because I've seen people
• 9:53
  out in the community do these fairly complex
• 9:54
  cases. The surgeon's very skilled, and the patient
• 9:57
  starts having a problem and some some staff
• 9:59
  member or someone else doesn't really know what
• 10:02
  to look out for and then a catastrophic
• 10:04
  complication ensues.
• 10:05
  So if you're gonna do this kinda work,
• 10:07
  you need to have,
• 10:09
  front desk staff and administrative staff, nursing staff,
• 10:12
  physical therapy,
• 10:13
  the OR, everybody who's used to treating this
• 10:16
  kind of thing. And that's why
• 10:17
  what we've done at Brown and the Miriam
• 10:19
  is built
• 10:20
  a very highly skilled team of people who
• 10:23
  actually have an interest in this problem.
• 10:25
  You can't just have people who say like,
• 10:27
  oh, yeah. Yeah. I I do orthopedics. It's
• 10:29
  that's not enough. It has to be people
• 10:32
  who know complex spine and spinal deformity. And
• 10:35
  then the the last thing
• 10:36
  is alignment. We've done a lot of work
• 10:39
  in spinal alignment.
• 10:40
  We're making some great progress in terms of
• 10:42
  figuring out optimal alignment for patients.
• 10:45
  And there's some very exciting
• 10:47
  products coming out in the pipeline,
• 10:49
  that will be, you
• 10:51
  know, specific
• 10:52
  patient implants for their alignment that I think
• 10:55
  will really continue to revolutionize
• 10:57
  complex spine and spine fusion care.
• 11:00
  So, like, lots of moving parts, it sounds
• 11:03
  like.
• 11:04
  Yep. Definitely.
• 11:05
  Yeah. And then just some last question for
• 11:07
  you, doctor Daniels. Can you just go through
• 11:10
  three big trends that you're following closest in
• 11:13
  health care today?
• 11:16
  Absolutely. I think
• 11:18
  I think the first trend,
• 11:20
  has to do with reimbursement as we talked
• 11:22
  about, but is also closely tied to value
• 11:26
  based and outcome driven care. I think they're
• 11:28
  all wrapped in together.
• 11:30
  Now we've been talking about value based and
• 11:32
  outcome driven care for a long time.
• 11:35
  And it's not like it's just all gonna
• 11:37
  be a wave and show up in the
• 11:38
  next six months or one year or two
• 11:39
  years, but it is coming,
• 11:42
  especially in spine because poor outcomes are not
• 11:44
  sustainable.
• 11:46
  And somehow, we as a field
• 11:48
  need to figure out
• 11:50
  how
• 11:51
  to
• 11:52
  help the insurance companies and help the payers
• 11:56
  with outcome driven care and value based care.
• 11:58
  And it's really hard because
• 12:01
  measuring outcomes is difficult.
• 12:03
  Centers like ours that take care of really
• 12:05
  complex spine problems, you know, we'll take patients
• 12:07
  from all over the region that have already
• 12:09
  had failed spine surgery. And the reality is
• 12:11
  though patients don't always do well. And so
• 12:13
  if we are purely in an outcome driven
• 12:15
  care model and we take those really tough
• 12:17
  cases on,
• 12:19
  there may be payers who don't wanna reimburse
• 12:22
  us well for that, because our outcomes are
• 12:24
  poor. And so I think it's going to
• 12:26
  take some collaborative effort between
• 12:28
  spine specialists, practice,
• 12:30
  hospital systems, and the insurers to figure out
• 12:33
  what that really means for outcome based care.
• 12:36
  The second would be
• 12:38
  also something we briefly touched on, which is
• 12:40
  data integration and AI enabled decision support.
• 12:44
  Basically meaning that
• 12:46
  we just must use data better
• 12:49
  to help deliver more evidence based care. Because
• 12:52
  if we don't do it, that variability is
• 12:54
  what's gonna kill us because it makes us
• 12:57
  look like we don't know what we're doing.
• 12:58
  And the people with poor outcomes can keep
• 13:01
  basically delivering that poor care at very high
• 13:04
  cost levels.
• 13:05
  And eventually, as we know, the payers are
• 13:07
  gonna look and say, we're paying way too
• 13:09
  much for spinal fusion and the patients are
• 13:11
  doing poorly. When in reality, if you look
• 13:13
  at the subset
• 13:15
  who are doing great,
• 13:16
  it's
• 13:17
  excellent care that's delivered at a very reasonable
• 13:20
  value. But I think we're going to need
• 13:22
  AI to do that.
• 13:24
  I think the the last thing is probably
• 13:26
  just the sustainability of the workforce, and and
• 13:29
  that's not just the spine surgeons and,
• 13:32
  coming from both neurosurgery and orthopedics. It's really
• 13:37
  figuring out how to keep,
• 13:39
  nursing staff,
• 13:41
  administrative staff, all the support staff,
• 13:44
  basically engaged.
• 13:46
  And it's a challenge because
• 13:48
  as we know, the
• 13:50
  expense of keeping really high quality staff is
• 13:53
  high. We've seen multiple
• 13:55
  union strikes from nurses here in our region
• 13:58
  and reasonably so. I understand it. It's because
• 14:00
  they have to vouch for their own
• 14:02
  livelihoods.
• 14:03
  But I think figuring out how to have
• 14:05
  true team based models
• 14:07
  will be really important. And we've had to
• 14:09
  fight that battle and we're continuing to regionally
• 14:11
  because
• 14:12
  everyone has a slightly different,
• 14:16
  viewpoint of what's important, meaning that the hospital
• 14:18
  just has to make sure there's nurses on
• 14:20
  every floor that can take care of every
• 14:21
  problem when I'm laser focused on making sure
• 14:24
  my spinal deformity patient has a nurse that's
• 14:26
  highly specialized in
• 14:28
  spinal deformity.
• 14:30
  And it works in relatively big hospitals, but
• 14:32
  as hospitals get smaller and smaller, of course,
• 14:33
  it's harder because you can't have ultra subspecialized
• 14:36
  teams and small subspecialty or excuse me, small
• 14:39
  community hospitals. So I think that's a challenge
• 14:42
  that we are gonna continue fighting and we'll
• 14:45
  look at different in different communities.
• 14:47
  Got it. Well, doctor Daniels, thank you so
• 14:50
  much for joining us today. It's a pleasure
• 14:52
  speaking with you, and I hope to connect
• 14:53
  again down the line.
• 14:55
  I really appreciate it, and thank you so
• 14:57
  much. Look forward to talking again at some
• 14:59
  point.