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- This is Laura Dirda with the Becker's Healthcare
- podcast. I'm thrilled today to be joined by
- doctor David Bernstein, a Harvard trained orthopedic surgeon.
- David Bernstein, it's a pleasure to have you
- on the podcast today. Thanks so much for
- having me. It's a pleasure to be with
- you. Absolutely. Now I'm excited for our conversation.
- I know a lot happening in orthopedics right
- now and in health care, in particular,
- you know, so many different things looking at
- the clinical side, looking at the business side,
- private equity, and more. So I'm excited to
- dig into these things with you. But before
- we do, can you tell us a little
- bit more about yourself and your background?
- Absolutely.
- So, as you mentioned, I, am a Harvard
- trained orthopedic surgeon, finished up orthopedic surgery residency
- in the Harvard combined orthopedic residency program,
- last month.
- But I've had kind of a bit of
- a, a winding journey from a career standpoint.
- I I've always been interested in the intersection
- of the business, politics, and delivery of health
- care. And part of that stems from, the
- fact that my dad's a pediatrician.
- My mom's a pediatric nurse, and I grew
- up,
- in a household
- where my dad loved what he did, and
- he loved his patients and
- but just couldn't understand why the health care
- system didn't work. It just it just didn't
- seem to work. It was there was always
- a concern about,
- something here or something there
- about why patients were struggling to pay for
- health care or why health care,
- didn't seem to deliver the outcomes that that
- had been promised. And so I was always
- interested in in why that was the case.
- It seems to me that health care is
- the one,
- area that everybody in the world,
- could benefit from from having it improved. Yet
- if you go to anybody on the street,
- I would suspect that no one would say,
- oh, the health system is is exceptional and
- it works well, whether that's in The US
- or or, frankly, anywhere across the world. And
- so that always puzzled me.
- And so that kind of set my my
- career trajectory.
- I went,
- to to Bowdoin College up in Maine,
- and absolutely loved it. And I actually majored
- in economics because I wanted to understand incentives
- and and what drives people to to do
- certain things and how can we use incentives
- to fix health care.
- And so that led me that led me
- to study economics always with the lens of
- what does that mean from a health care's
- perspective.
- And fast forward,
- a few years, I I lived in Europe.
- I tried to understand the the European
- models of health care. Obviously,
- being American, trying to understand the American models
- of health care, and I enrolled in a
- dual MD MBA program at the University of
- Rochester,
- again, with the goal of how do I
- marry my interest in delivering one on one
- patient care but making a broader impact,
- broader positive impact from the health system perspective.
- Because in my mind, if you can move
- the needle just a little bit, you could
- have an impact,
- across tens of thousands, if not millions of
- people instantaneously.
- And so I enrolled in in in that
- dual MDMBA program,
- learned, learned a great deal. And as I
- was nearing the completion
- of that, I had the remarkable opportunity to,
- to join Michael Porter and Bob Kaplan at
- Harvard Business School as their senior researcher in
- health care and value based health care,
- to really, again, dig into this question about
- how do we fix the challenges we're seeing
- in health care to make a positive difference
- in the lives of of many.
- So I worked at Harvard Business School for
- for,
- a bit before transitioning to residency,
- at Harvard
- and then having just completed it. And so
- I've always been at this odd intersection of
- the business, politics,
- and clinical care delivery side of health care,
- and that to me is is the most
- exciting area to be in as we look
- to solve some of the challenges we face
- both in orthopedics, but frankly, across health care
- more broadly.
- It makes a lot of sense. You know?
- And it's a really impactful kinda origin story
- for your passion in health care and how
- exactly you came to to be in this
- space, which is really exciting.
- What's it been like, you know, training as
- a physician and
- in such a a a,
- transformational time in the health care space? What's
- that been like?
- Yeah. It's it's it's been it's been exciting,
- I think. One of the things that's very
- interesting is when you talk to a lot
- of people and say, oh, I'm gonna be
- in health care. There's a lot of physicians
- out there who say, oh, I don't know
- if now is the time to to to
- be in health care. To me, this is
- actually the most exciting time to be in
- health care. It's a time of great need
- and great challenge. And to me, whenever there's
- a challenge, there's an opportunity, and that opportunity
- is to help fix some of these some
- of these issues that we see.
- It's been challenging, but it's been challenging and
- exciting at the same time. And so
- one of the things that's really nice about
- training,
- to be clinically,
- relevant, if you will, and clinically driven is
- that you see the the challenges that are
- described at a 30,000 foot view onto on
- the one to one level. So whether it's
- price transparency
- and health care access,
- which health care access does not equal health,
- by the way, and we can discuss that
- a little bit more too.
- But whether it's health care access, whether it's
- obtaining and and staying healthy, whether it's health
- care price transparency,
- you see that at the ground level on
- these one to one patient interactions when patients
- ask ask you questions. And then when you
- take a 30,000 foot view and you start
- discussing kind of what are policy changes or
- health system changes that we can actually implement
- to drive
- progress,
- you can start to marry those two those
- two realms. And so I've found training clinically
- to be incredibly,
- powerful,
- both as a tool to learn what matters
- most to patients, but also as a tool
- to really drive that one to one positive
- change so that when you see these
- challenges at a 30,000 foot view, maybe taking
- longer than you want to actually make progress,
- you can go back, help patients one on
- one, and also see see their progress individually.
- And, ultimately, at the end of the day,
- as long as you move the needle for
- everybody, you're you're improving the health of the
- population. And so it's been exciting,
- challenging,
- and something that gets me up every morning,
- ready to go to work.
- I love that. I think that's such a
- great mindset and approach when you're thinking about,
- you know, all the the big challenges within
- health care and in accessing health care and
- then boiling into, you know, where the innovation
- can happen and what makes the biggest difference
- for the patient population you're working with. I
- I'm curious. What are some of the the
- things that you've been most focused on and
- excited about right now within health care and
- within orthopedics in particular?
- Yeah. So I think the future of orthopedics
- is actually incredibly exciting.
- It's really undergoing a huge structural shift that's
- that's been ongoing for a while, but it's
- it's expedited
- recently.
- So kind of how, where, and by whom
- is care delivered.
- So historically, orthopedics and many of the surgical
- subspecialties
- have been within the four walls of a
- major traditional
- hospital,
- and it's now being decentralized.
- And they're being it's being moved to ambulatory
- surgical centers and and different Medicare and Medicaid,
- interventions are kinda pushing the boundaries of what
- it means to deliver orthopedic care. And so
- we're taking this model and flipping it on
- its head. How do we deliver
- the best orthopedic care to patients
- when they need it, where they need it,
- while being rewarded for delivering the outcomes that
- actually matter to
- those patients.
- And, honestly, it needs to be driven by
- orthopedic surgeons. If it's driven by those who
- don't deliver the care, which a lot of
- health care, frankly, over time has been driven
- by policymakers and those who don't understand what
- it means to deliver care,
- that's when patients lose, and that's where the
- that's when the subspecialty
- fields within orthopedics and orthopedics more broadly lose.
- And so it really this type of change
- is coming, and it's coming from regulatory frameworks.
- It's coming from financial
- base frankly, requirements in order to be financially
- sustainable.
- And so this needs to be driven by
- orthopedics,
- and orthopedic surgeons themselves,
- to deliver this coordinated care.
- So two
- well, two or three areas that I kinda
- think are really, really important today.
- As I mentioned, a lot of
- the the traditional thinking of health care and
- orthopedic surgery being delivered within the four walls
- of a hospital is just no frankly no
- longer the case.
- And so ambulatory surgical centers are super, super
- exciting. And they're not exciting just because
- they are,
- the hot and and and sexy area to
- receive care, but they're exciting because you can
- deliver
- care at a cheaper price that's frankly better
- in a area that patients
- live in already.
- It
- that has better parking, that has better patient
- experience,
- and can
- really shift
- the the model of care of care delivery.
- And we're seeing that actually from a regulatory
- perspective too as CMS revises or removes many
- of its inpatient only,
- list of surgeries
- to really allow,
- orthopedic surgeons to deliver care to patients in
- an area that that is best for them.
- We're also seeing
- increased in artificial intelligence and virtual physical therapy
- and digital health platforms
- that really allow patients to engage
- with their orthopedic surgeons and their orthopedic care
- teams in a more meaningful way than has
- historically been done. And this allows
- patients to
- to frankly
- receive better care and and hopefully improve clinical
- outcomes.
- And the last thing I'll say is
- we're also seeing changes,
- in in measurement
- in measurement of prices,
- in measurement of the of the cost of
- care, and how those direct bundle payments and
- measurement of patient reported outcome measures that are
- now included in many of the CMS,
- and CMMI
- models
- are playing into how we better understand,
- how our care is being received by patients
- and how that leads to the outcomes that
- matter most to them and how do we
- optimize those outcomes
- for them. And so all of these things
- that have kind of been historically written in
- this paper or that paper as a theoretical
- are now becoming the reality on the ground.
- Well, that's so exciting to hear. And and
- certainly thinking about that patient experience and then
- marrying the technology along with,
- access to care and in connection with the
- specialists that are are, all working together to
- help the patients in along their care journey
- is so critical.
- And then thinking through the value piece too,
- I know there's been a lot of fits
- and starts over the last few decades when
- you think about value based care in particular
- in orthopedics. And so,
- what makes this different? Where do you see
- as being, the the the elements of all
- of this that are are going to help
- it stick and and really make sure that
- the orthopedic patient population is,
- not only having everything available, but adopting it
- and really optimizing
- what they have in order to achieve the
- outcomes they want? It's a great question.
- And I think there's,
- what's really gonna make this stick today
- is there's political, financial, and operational challenges
- that require it to stick today. And the
- thing that I think is most important to
- touch upon is the term value based health
- care often gets one of two responses.
- One is you get an eye roll. You
- get this eye roll of, oh, this is
- a this is this is simply cost cutting.
- Or you get this
- response of, oh, this is gonna save health
- care. And I think what the reality is
- is we need to understand what value based
- health care actually means,
- and then we can start to implement it.
- And that the reason I say that is
- there are a lot of things out there
- that are called, quote, unquote, value based health
- care that are not value based health care.
- And and so for example,
- we use the term bundle payments
- to,
- to talk about how we deliver care,
- over
- a set good a set a set of
- services, for example. But actual bundle payments should
- be
- cover a
- condition, not the delivery of a total joint
- replacement.
- If you give a bundle payment just for
- joint replacement, for example, that's really just fee
- for sale service on steroids, and you're just
- expanding
- the the
- the fee and you're expanding the number of
- services, but it's not actually taking care of
- a patient's condition. And it doesn't actually incentivize
- you necessarily
- to deliver care long term,
- at at the outcomes that matter most to
- patients.
- And so I think we need to be
- careful a lot of times when we talk
- about value based health care and the terms
- within value based health care to make sure
- that we're not just using a term
- that
- sounds sexy, but then actually not
- implementing it in a way that's that's true
- to to the value based health care ethos.
- A couple things that I think, are are
- really are really important as well.
- One is
- value based health care is simply a strategy.
- It's not a payment model. It's not just
- measuring outcomes.
- It is the idea of how do we
- deliver and
- and by measuring those outcomes that matter most
- to patients, how do we deliver the best
- outcomes
- for patients?
- And then once we understand that, how do
- we do so efficiently to reduce cost?
- And so if you think of this, the
- quote unquote,
- famous formula, it's not really a formula, the
- outcomes per dollar spent. It's really a relationship.
- And if you understand that relationship, you then
- understand a strategy
- In the sense that if something increases
- the outcomes or improves the outcomes,
- but does not change
- the cost, you do that every time. If
- something doesn't change the outcomes, but it reduces
- the denominator or reduces cost, you also do
- that every time. What the challenge we face
- today is what happens if something increases the
- outcomes or improves the outcomes and increases the
- cost? Do we do that? Or what if
- something decreases the outcomes
- or reduces the outcomes and decrease the cost?
- Do we do that as well? And that's
- why orthopedic surgeons need to be leading this
- because those nuanced decisions
- require their insight into what matters
- clinically, what are we measuring, and is what
- we are measuring really what's most important to
- patients. And if we don't have orthopedic surgeons
- at the table, that's when we get into
- trouble.
- That's such an excellent point. And, you know,
- it's so critical when you strip down whether
- it's body based care or anything else, having
- that kind of understanding of the patient and
- knowing what moves the needle for them and
- and then being able to truly design that
- into,
- the health care delivery system on both the
- clinical as well as financial side,
- makes a huge difference. And so I I
- can certainly appreciate that. And I think especially
- for surgeons like yourself at the beginning of
- their careers, you know, what do you as
- you're looking onto the orthopedic field and, you
- know, thinking about the future, where do you
- see the biggest areas for growth? What is
- kind of the the spaces where it makes
- the most sense to attack and and tackle
- first? And then looking at true transformation and
- what's gonna be possible in the next couple
- decades.
- How do you think about all of these
- things and then,
- incorporate it into the career and practice that
- you're building?
- Yeah. It's a it's a really,
- it's a really, really
- good question, and it's a big question. So
- I think,
- it's no secret that the population is aging.
- And it is no secret that technology
- and,
- including digital health tools and AI
- is booming and only gonna grow. And so
- as I think about the start of my
- career,
- I think about how do I integrate
- these tools and instruments
- to deliver on that strategic goal of value
- for patients, of improving outcomes
- while while making it efficient and keeping costs
- the same or reducing cost. And so one
- of the challenges is there's so many interesting
- and cool gizmos and gadgets and tools and
- instruments
- out there.
- But does it do they
- achieve
- the the strategy that has been laid out?
- So as I think about my
- career trajectory and career
- aspirations,
- I wanna make sure that I implement and
- utilize tools that allow me
- to improve clinical outcomes. But what does that
- mean? That means that I have to actually
- measure those outcomes. And I think measuring those
- outcomes that matter most to patients should be
- as routine
- as taking up someone's blood pressure and their
- vital signs.
- As orthopedic surgeons, I wouldn't operate
- on someone without an x-ray. So why would
- I
- deliver a care
- journey,
- expectation
- without understanding their goals, without understanding
- what their functional status is, without understanding what
- their pain level is in a way that's
- actually tangible and and real and not just,
- oh, I have pain today. Oh, I'm not
- functioning at the ability I want to, but
- really digging into
- validated ways of measuring that.
- And so I'm super excited about these technologies,
- but I also wanna take those technologies,
- implement them in in a learning health system
- type model, in a quality improvement rapid cycle,
- and say, yes. This works. This doesn't. And
- I want the flexibility in order to do
- that. And that requires
- a health system that understands
- that the changes and challenges of tomorrow can't
- be solved with the instruments and tools of
- yesterday.
- And so that's what I'm super, super excited
- about. That includes those AI tools, as I
- mentioned, robotics,
- orthobiologics,
- smart implants. All of these things have remarkable
- potential,
- but we have to make sure we're not
- just using them because they're the sexy thing
- to do in today's world, but that they
- actually
- improve patient outcomes that matter most to patients.
- That's amazing to hear. I I love that
- and truly inspirational about what the future may
- hold.
- Thank you so much, doctor Bernstein, for being
- here on the podcast today. Is there anything
- you want to leave our listeners with?
- Thank you,
- for having me. It's it's truly been a
- pleasure talking with you,
- and, I'm just excited. I'm excited about the
- future of health care. Most people, as I
- mentioned,
- today are
- care is broken. I don't think you'll find
- a single person in this country or frankly
- around the world, as I mentioned, who would
- say health care,
- is fantastic.
- But what's exciting about is that we have
- an opportunity to chart the the next
- twenty, thirty, forty, fifty, a hundred years of
- health
- care. And by doing so, we can make
- the changes
- that align the incentives,
- that
- reward delivery of exceptional patient care,
- and that ultimately leads to a healthier population
- that can,
- play with their families, deliver economic prosperity,
- and can really make a difference in the
- world. And so to me, this is the
- most exciting time to be in health care.
- And that's, I think, the that's
- why I wake up every day excited,
- for the day and and what I do.
- Excellent.
- Thank you so much again for your time
- today. This has been a really fun conversation,
- and I look forward to keeping it going.
- I know, you know, a lot coming up
- ahead, so we'll definitely have to stay in
- touch.
- Fantastic. Looking forward to that.