Hi, everyone, and welcome to the Becker's Healthcare
podcast series. I'm Lucas Voss.
Very excited to be joined by doctor Marvin
k Smith and doctor Daniel b Chan.
Lots of prolific expertise here for our conversation
around sports medicine and the ASC environment
as a whole. Doctor Smith, doctor Chan, thanks
so much for being here.
Thank you. Thank you for having us.
Thank you for having us.
Absolutely.
I'm excited to dive in. We have so
much to talk about here. There's so so
many different aspects to to consider. And and,
doctor Smith, I just wanted to start off
with you. If you could just introduce yourself
to the audience a little bit and how
you came to specialize in sports medicine, and
then even more specifically, what brought you into
the ASC environment,
today?
Yes. So, my name is Marvin k Smith.
I'm a orthopedic surgeon, board certified, and fellowship
trained in sports medicine. I'm from South Florida
originally. My background is sports
participation. I was fortunate to play division 1
college football at Central Michigan University,
and I've always had a love and a
passion for helping athletes, working with athletes.
And, it's been my passion to try to
restore others back to their passion.
And with that, that really lends to working
with ASCs.
Sports medicine cases were amongst
the first cases to be done at ASCs
and continue to be a good fit for
that model. And I'm really happy to be,
a part of a very successful ASC
to this day.
I did save, doctor Smith's number just in
case I have questions about injuries for my
fantasy football team. So if you're interested in
that, just,
hang along and then we'll share that at
the end. Just kidding.
Doctor
doctor Chan, same for you. What what's, what's
your background and and how how how was
your approach, in in AAC in general, and
how did you come to specialize in the
area?
Sure. I'm an orthopedic trauma surgeon by training.
I've been in practice about 15 years now.
Over time, my practice has migrated more and
more to doing total joint replacements,
specifically hip and knee replacements and the revisions.
And about 5 years ago,
it just seemed like a natural move
to move these cases to the ASC.
Here in South Florida,
there was not much of an ASC presence
at that time. And so it was a
nice opportunity for us to move these cases
that we were already doing as outpatients in
the hospital
into the ASC setting really to provide,
a benefit for the patients and, a more
cost effective,
environment in general.
And we've really leveraged that to our advantage.
We're now our ASC at Cypress Creek is
the leading orthopedic ASC in South Florida and
definitely the leading ASC for outpatient hip and
knee replacement.
That's awesome. And we'll touch on and we'll
touch on that in a little bit more
in a little bit more detail in talking
about some of those aspects for you and
for your for your business specifically.
Doctor Smith, I I wanna come back to
to you, a little bit here,
specifically to,
to to ASCs and and the transformation that's
that's been under that's the field really has
been undergoing for for quite some time now.
How has the environment changed since you first
started practicing,
in terms of the site of care and
just in general? What are some of the
these transformations that you've observed?
Well, I've definitely seen,
an evolution
of the types of cases that we're doing
at ASCs even within the sports medicine subspecialty.
Initially, it was solely arthroscopic
surgeries
and and very small open surgeries, whereas now,
the envelope has definitely been pushed where we're
doing
even more open,
have the ability to do more open sports
medicine procedures,
larger
ligament and soft tissue reconstructions
in the ASC settings. And it also lends
to what doctor Chan was alluding to, you
know, obviously on the total joint side, really
expanding what we're doing and taking that model
and that mindset that, well, if we're discharging
patients from the hospital same day for these
surgeries,
then do we really need to do them
in the hospital setting,
per se?
And, that's one of the biggest shifts that
I've seen is, you know, when people think
of sports medicine, they tend to think about
minimally invasive arthroscopic, which is definitely a a
large share, maybe even lion's share of those
cases. However, there's a very significant
part of sports medicine surgery that does involve,
larger cases.
Yeah. Doctor Chan, same for you here. What
what sort of been your perspective on how
this this field has transformed over the last
last decade or so and even since you
you began your career?
I think initially when we started doing total
joints in the ASC, it was just a
proof of concept. This show that it could
be done safely,
to show insurance companies that we could have
good results, and that this should be something
that they would,
reimburse for. Mhmm. But now I think as
things get more mature, it's about efficiencies and
how can we really
leverage the ASC as an efficient side of
care to really do more cases,
while maintaining patient
safety and really,
expanding the scope of the procedures we're doing.
So we're we're even doing some basic revision
hip and knee replacements in the ASC.
So it's just an expansion of both the
type of cases and the efficiency and quantity
of cases that we're doing, which has dramatically
changed even in the past 4 to 5
years.
Yeah. So we're really moving you mentioned proof
of concept. So we've
we know it works.
So now it's now we're getting to optimizing
this whole this whole area. Is that correct?
And and being able to to kinda see
what what's next. How can how can we
take this to the next level? Is that
sort of where we're where we're at right
now, doctor Chen?
Absolutely. I think,
there's gonna be a certain limit, obviously, and
I know some people really focus on the
number of cases.
I think I really focus on just being
efficient, and, ultimately, patient outcome should be the
driving factor.
I think as we see more and more
changes
in terms of how health care is reimbursed
and pressures from CMS and private insurance,
companies,
there's gonna be more,
interest in alternative, payment structures, either value based
care
or for us some medical tourism since we
are in South Florida. Mhmm. I definitely attract,
you know, patients from the Caribbean, South America,
out of the country.
And so leveraging that with the ASC benefits
really makes, an an attractive package for patients
looking to seek premier care in a an
efficient kind of cost effective setting.
Yeah. Absolutely. Doctor Smith, I wanna come back
to you here as well. And and I
was wondering if you could touch could touch
a little bit on on the technology
side of things as well in terms of
how it's changed. How are you seeing it
evolve
still consistently, and and what are sort of
the things that you're you're using you're seeing
really make a difference from a from a
technology perspective?
That's one of the things that I really
love about medicine in general and, you know,
specifically orthopedic surgery that technological advances are just
continuing to
occur year over year. A lot of changes
even since the time that I trained in
fellowship,
just seeing the capabilities
of different devices.
I like to use the
Dynacord suture and many of my cases
that require good tight suture fixation because that
actually is a suture that gets tighter with
time as opposed to looser over time. That
contractile,
central cord really can make a difference as
opposed to,
noncontractile sutures as far as your healing rates
and compression for your your
tensioning.
So those are some of the things that
that we're using, that we're seeing. I like
a lot of the more ergonomic
meniscal repair devices that,
really help you get various angles when you're
dealing with a lot of complex meniscus repairs.
I'm very aggressive,
when it comes to repairing menisci,
as I do serve a very active and
tends to be a younger population.
Many of my patients are professional and
division
1, elite level college athletes. So if we're
able to preserve the meniscus as opposed to
resect the meniscus,
it can make all the difference in the
world. And, I've found that some of the
newer technologies,
like TruSpan, for example, have really allowed me
to do things that might not have otherwise
been possible.
Yeah. Doctor Ken, interested in your perspective here
as well in terms of just the changing
of technology in general and and how you've
how you've seen this really influence,
the environment,
within the ASC and and practice in itself?
Absolutely.
We partnered with DE PUA from the very
inception of our time in the ASC,
just basically bringing over the same technologies we
were using in the hospital. And
like it or not, orthopedic surgery is the
most patient consumerism driven specialty in all of
medicine. So people or patients, I should say,
will search online for specific techniques, technologies, and
they come to the office asking for them.
And so initially, it was, you know, do
you do anterior hips? Do you use a
special table? Then it was, do you use
robotics? Do you use advanced navigation?
And so patients come in,
expecting that their surgeon,
utilizes these latest technologies. And
fortunately, where we have been, we've been able
to leverage all those technologies from DPU. We
started with the Velas hip navigation system, which
really allowed accurate reproducing of leg length and
offset during hip replacement procedures.
We utilized the, Kinsize automated impactor to make
for,
a more precise broaching.
We've added the Velas robotic knee system
recently,
for both total and soon partial knee replacements.
And so all of these all of these
things really give the patients the latest technology
when they come in for the joint replacement
procedure, which is really what they're expecting,
in this day and age.
And I would assume also with with all
of these innovations and all of these new
tools, there's a huge driver in efficiency as
well. Doctor Smith, I was gonna ask too.
I feel like especially with high level athletes,
right, that need to be, you know, in
some cases, either need to be on the
field right away or they need, hey. I
have a week to get this done. I
feel like that that if the efficiency piece
is huge, is that where technology really makes
a difference too in terms of providing that
efficient,
efficient care, being able to say I can
I can do this now versus having to
wait?
Certainly. Having the ability to have a higher
level
of,
specificity
of
accuracy
with your cases
can allow you to be more efficient. And,
you know, we're very fortunate in our ASC
at Cypress Creek. We have a tremendous team
who they're very familiar with the cases that
we do as it relates to orthopedics. So
we're able to move efficiently and safely,
and that obviously opens up more access for
our patients. And that gives us the ability
to maybe add on that patient,
that was just seen in the office a
few days ago. But by virtue of their
career, it really makes all the difference if
we can get them in a few days
sooner. Yeah. So the technology is definitely a
contributing factor that helps us be successful in
that room. Yeah. Absolutely. And I know you've
both mentioned this a little bit. I love
this question because I think it's so it's
so interesting because of the innovation and because
of everything that's that's been going on, and
and certainly you both have mentioned how how
everything has changed. And and, doctor Chan, I
wanna start with you here.
What is sort of the one tool, instrument,
or technique that you wish you would have
had when you first started your career?
I would say without a doubt, it would
be the, Kinsight's automated impactor.
Now as somebody that does, you know, several
100 total hip replacements a year,
not having to,
swing a mallet or a hammer at all
during that case. And on days when we
do up to 10 pivotal joints a day,
that's a huge,
preservation,
and mitigation of any occupational,
hazard
for the surgeon as well as providing the
precise bone preparation
and accuracy for the patient. So if I
had that in the very beginning, I'd probably
have a lot less tennis elbow and, CMC
arthritis.
Doctor Smith, same for new same for you
here. What what's the number 1?
I I have I have several, but if
I have to pick 1,
I would say
the Milagro screws, the bio absorbable interference screws,
I use them for my ACL reconstructions when
I am doing bone patellatin and bone grafting
technique.
I also use them
for MPFL reconstructions
and I really prefer
to avoid leaving metal behind
in the patient if I can,
particularly we're working with soft tissue reconstruction. So,
there is an alternative
to metal fixation. Many patients prefer that. Many
patients have strong convictions
about metal. And, I'm really happy that's become
more commonplace, whereas,
maybe years ago and just starting off, it
wasn't as common. And we've been very fortunate
to work with our ASC and working with
Depew on getting very,
ASC friendly rates for those products, even coming
in comparable to competitors' Meta Splus.
Feel like we should just do an episode
on these tools.
I think that would be
I'll I'll bring you both back and we'll
talk about the we'll talk about the most
important tools and the the number 1, and
then we can we can do a complete
ranking. We'll do 1 through 10 of what
you would have liked to have and and
then the best ones. I I think that's
a good
that's a good approach there.
Doctor doctor Smith,
with your expertise in in sports medicine specifically,
these were some of the cases that were
some of the earliest
move to ASC settings,
that that were moved to in out in
terms of outpatient surgeries, etcetera.
Obviously, there's others. You talked about total knees,
hips, shoulders, etcetera. We we have all of
those as well. With with the reimbursement of
these higher acuity,
procedures that I just mentioned,
how does your facility look at procedure mix,
OR time allotment,
and and certainly also the recruiting of surgeons
with different,
specialties?
What role does that play,
and and what what what kind of impact
does it have?
It definitely behooves the leadership in NAFC to
be very intentional at looking at the case
mixes,
looking at not only reimbursements, but also
operative efficiencies, looking at how teams can move
in and out of cases, scheduling
surgical days in a way that, you know,
even if you do have a surgeon that
may do open surgeries, may do a lot
of arthroscopy
arthroscopic surgeries,
scheduling those days where you try to have
more of the arthroscopic surgeries on the same
day. So you're not having to do as
much work for the room turnovers and scheduling
those open cases and kind of clustering them
together,
clustering the total joints together on a day
where you can get things done. But also
keeping in mind the sterile processing aspect of
it,
and making sure that those trays can get
processed and flipped around so that you can
continue to move forward with those cases. There
are so many moving parts. And even though
sports medicine did lead the charge as it
relates to orthopedic cases in the AFC,
We now have such a wide variety of
orthopedics that there's really not much that can't
be done. There's so many cases that we
are able to do. So with that, it
does behoove us to really be intentional about
how we plan that. And it also really
opens up the door to recruiting surgeons of
various specialties outside of sports medicine
to service the ASCs and the patients that
seek care there.
Yeah. I would assume that that's a huge
huge business case as well. Doctor Chan, feel
free to feel free to chime in here
as well in terms of the impact that
has on the business itself when you're able
to offer all of these types of these
types of surgeries and and certainly in the
in the recruiting aspect, interested in your your
perspective here as well.
Well, certainly, in the ASC market, there are
different types of ASCs.
I would say ours is a multispecialty
ASC, so there are some ASCs that just
do total joints or just do sports medicine.
And so,
when it comes to an ASC that has
more breadth of types of specialties that are
offered,
there are a lot of different factors that
you have to consider.
At the end of the day, the ASC
is a for profit entity, and so everything,
you know, has to start with is this
is gonna be financially viable for the ASC?
But that goes beyond just,
what the insurance company or the payer will
will reimburse for the case. It depends on
the disposable. It depends on, you know, how
fast the surgeon is. You could have you
know, if a surgeon takes, you know, too
long to do a case, the case no
longer become profitable. And so those are the
issues that matter,
more and more as
OR space becomes more limited.
And so we use very advanced metrics even
looking at, you know, what's our revenue or
profit per minute in the OR per procedure
per surgeon. And so when you get down
to that granularity, you can really
figure out how best to allocate limited resources.
And then looking ahead, we're always looking at
specialties that potentially
are a a new horizon in the ASC
field. And so,
obviously, orthopedics has always been, at the forefront,
but now we're looking at things like cardiovascular
procedures, like,
you know, basic angiography
or, you know, peripheral interventions
or even pacemaker
implantation. So those things are kind of more
cutting edge.
But if an ASC is to remain viable,
we need to be,
you know, looking at a multipronged approach.
Yeah. And a and a big piece of
this too is, I I would imagine, is
is partnerships and collaborations
and and seeing where where that financial financial
piece really lies in terms of partnering with
folks and seeing where they're at.
How do you choose? What are the collaborations
in terms of business planning,
that you look at? Okay. How do I
choose my partners? What do I look for?
How do you choose the right
partner to support some of the things that
you've just mentioned?
I I think one of the key aspects
of our initial success,
from day 1, and we were profitable from
day 1, which is very uncommon for ASCs.
But I think in large part, it was
due to our
collaboration with J&J Medtech and Depew.
And, really, it was a continuation of relationship
that started in the hospital, but we designed,
the ASC
orthopedic endeavor with
that partnership in mind. And so,
when you go all in with one company,
it just allows for a lot more efficiency,
a lot more benefits in terms of,
multiple platforms. So we have general surgeons that
do hernia repairs that will use Ethicon. Obviously,
we use Ethicon suture. Doctor Smith will use
MyTech products for sports medicine. I'll do Depute
Total Joints. When I fix fractures, I'll use
Synthes.
And so getting that multiline
support, which ultimately will
contribute to rebate dollars that goes back to
the ASC, has been very beneficial.
It's allowed for us to acquire technologies
like the, Velas robotic system,
and it also allows for just economies of
scale, and we have a dedicated team. And
so all those things will really make it
a win for all the stakeholders and especially
the patient.
Yeah. I was gonna say keeping that that
in mind as well, who is who is
really focused on on patient care, patient outcomes,
and being able to support some of the
goals that you you as an organization have
as well and having some alignment there. I
think that's a that's a really great point.
Doctor Smith, I wanna look ahead a little
bit in terms of what developments and opportunities
you're really looking forward
to in sports medicine, in ASCs. I feel
like this is such an evolving field. You
mentioned new procedures, new tools. We talked a
little bit about that.
What are you most excited about in the
next couple of years about some of the
innovations that are that are coming?
So there's so much that we can do
in sports medicine now. I really enjoy cases
like cartilage restoration
and complex ligament reconstruction
Mhmm. And even meniscal allograft transplants.
When it comes to ASC, though, you do
have to be mindful of
allograft cost.
So that's one of the things that I
would love to see in the future if
we can start getting some of the cost
down or some of the allografts, some of
the cartilage restoration,
constructs, or also the sets that are required
to perform surgeries.
I would love to see us do even
more. There are some of those
but there's been there's definitely been some good
work being done. There's some of those cartilage
restoration procedures that originally you had to convert
to open that now there's some technology where
you can do them all arthroscopic,
and looking forward to see what's on the
horizon with that. Out of the what we
are accomplishing
at our ASC, as doctor Chan said, we've
been profitable since inception.
Year to date, we've done well over 1500,
orthopedic sports medicine cases at Cypress,
just this year so far, and that was
actually up just until September, and we're looking
forward to grow even beyond that.
Doctor Chan, feel free to chime in here
too. Very interested in your your future outlook,
so to speak. What what are you most
looking forward to?
I'm looking forward to just doing more and
more complex cases in the ASC. I've mentioned
briefly,
revision total joints,
especially on the knee side
where
it's very amenable to that.
Obviously, when we talk about revisions, the pricing
is the biggest constraint,
and then the reimbursement thereof.
But I think, as again, from a proof
of concept perspective, once we can show the
the payers that we can do these,
safely and effectively,
we'll start to move in that direction.
And then I think channeling back my previous
life as an orthopedic trauma surgeon,
I think being able to perform
outpatient fracture surgery in a timely fashion will
be a great benefit to both patients and,
the health care system in general.
It will help decompress the ERs
at most, major hospital systems. So I think
finding ways to align with hospital systems or
orthopedic urgent cares to
allow these fractures that can be,
done efficiently in the ASC setting will provide
benefit to everybody.
Yeah. And if if trends and numbers or
any any consideration here, I think this is
only going to grow. This is a trend
that hasn't really stopped, I say. I'd say
within the last 5, 6 years. We hear
stories coming out all the time and and
mergers, acquisitions, etcetera. So I think that ASC
trend and and being able to to do
some of the things that you've described throughout
our conversation here is is really key.
Doctor Chen, coming back to you here real
quickly. We we talked a little bit about
recruitment and being able to sort of diversify,
making sure you find folks that are that
are cape first off, capable and also have
different specialties,
etcetera.
I wanted to touch on your center status
as sort of a center of excellence
and the the,
preceptorships
that you're you're offering. And I was wondering
if you could touch a little bit about
that program and what that means for the
future too.
Sure.
I think we are one of only 7
ASCs in the country through J&J Medtech that
offer this program.
And the nice thing is that it's really
an a la carte program,
depending on what the surgeon or or his
or her team is looking to,
learn more about.
And so we've had the gamut where we've
had individual surgeons, come by themselves or they
bring their
Velas robot, Velas Hypnab, the Kinsize.
How do we do that in an outpatient
setting? How do we move efficiently room to
room?
And they can see that. We also host,
surgeons for cadaver labs to get practice hands
on training with those that we proctor.
We've even had,
surgeons bring their entire team,
including anesthesiologists,
nursing, business staff,
from the ASC or their hospital usually.
We've hosted books from Brazil, from Singapore,
from Japan.
And so we're looking forward to just bring
that, to whomever's interested. And certainly, I think
we were seeing a lot of international interest
commonplace. You know, in Europe, you still see
patients staying in the hospital for a week
after a routine primary total joint. And so
there's great interest
internationally
to learn some of the efficiencies that we've,
mastered here, in South Florida.
Yeah.
Doctor Smith, same for you here. Does, how
much of a role does professional education really
play in in this field, especially because it's
moving so fast? And I feel like there's
a there's a constant need for for professional
education and and being able to to keep
up with what's going on.
Certainly. You know, everything is evidence based, and
as we get better evidence and more literature
and more information,
our practices evolve and with that technology also
evolves with it. So continuing to stay at
at the peak of professional education, I think
is paramount.
I've been fortunate to be involved with J
and J Medtech as it relates to doing
and conducting local labs and also being a
part of the Future Leaders Conference
earlier this year, which, was a great conference
and, was happy to be part of it,
I
believe. Moving forward, I'm happy that we do
have it our center of excellence for preceptorship.
I'm looking forward to making myself more available
for that, balancing with my responsibilities
covering our major league professional rugby team and
our our local colleges and their sports teams
and all of their needs. But,
balancing all of that, I also wanna make
myself available to my colleagues,
both local and abroad.
That's that's awesome. I'm I'm I'm really glad
that you're you're really providing I I think
you're providing a a great service to the
community there too, being able to help help
folks
be back quicker. Right? Be on the field
quicker, especially young athletes. I I it's so
important to be able to have that experience
and being able to return, to whatever the
court or the field,
as fast as possible. Doctor Chan, doctor Smith,
thanks so much for being here. Really enjoyed
our conversation. Thanks so much for taking the
time.
Thank you. Appreciate it.
Alright. It was a pleasure. I'd also like
to thank our podcast sponsor, Johnson and Johnson
MedTech. And for more information on the ASC
preceptorship program by the Johnson and Johnson MedTech
Professional Education team, please reach out to the
following email,
ascstrategicthoughtleadership
atits.jnj.com.
This email is also included in this episode's
description. And you can tune into more podcasts
from Becker's Healthcare by visiting our podcast page
at beckershospitalreview.com.