1 00:00:00,160 --> 00:00:01,459 Hi, everyone, and 2 00:00:01,839 --> 00:00:03,459 welcome to the Becker's 3 00:00:04,080 --> 00:00:06,019 Spine and Orthopedic podcast. 4 00:00:06,399 --> 00:00:08,900 I'm Sophie Ades, orthopedic reporter 5 00:00:09,519 --> 00:00:10,900 with Becker's Healthcare. 6 00:00:11,279 --> 00:00:13,919 And today, we're honored to be joined by 7 00:00:13,919 --> 00:00:14,419 doctor 8 00:00:15,234 --> 00:00:18,515 Alexander Vaccara, one of the most respected leaders 9 00:00:18,515 --> 00:00:21,335 in spine surgery and orthopedic care. 10 00:00:21,714 --> 00:00:25,314 He serves as president of Rothman Orthopedics and 11 00:00:25,314 --> 00:00:26,214 is the Richard 12 00:00:26,594 --> 00:00:27,094 h 13 00:00:27,609 --> 00:00:30,829 Rothman professor and chairman of orthopedic surgery 14 00:00:31,449 --> 00:00:33,710 as well as professor of neurosurgery 15 00:00:34,649 --> 00:00:36,510 at Thomas Jefferson University. 16 00:00:37,210 --> 00:00:39,390 Doctor Vaccaro's career spans 17 00:00:39,734 --> 00:00:40,554 clinical excellence, 18 00:00:40,934 --> 00:00:43,674 academic leadership, and health system strategy. 19 00:00:44,375 --> 00:00:47,335 His work in spine trauma and research has 20 00:00:47,335 --> 00:00:48,074 helped shape 21 00:00:48,614 --> 00:00:51,914 modern spine care, earning the trust of surgeons, 22 00:00:52,214 --> 00:00:52,714 institutions, 23 00:00:53,760 --> 00:00:55,539 and patients around the world. 24 00:00:56,079 --> 00:00:59,039 In this episode, we're gonna explore what lies 25 00:00:59,039 --> 00:01:02,659 ahead for orthopedic and spine care in 2026 26 00:01:03,119 --> 00:01:03,859 from innovation 27 00:01:04,159 --> 00:01:06,980 and workforce evolution to leadership lessons 28 00:01:07,585 --> 00:01:09,745 and the strategic growth of one of the 29 00:01:09,745 --> 00:01:10,805 nation's largest 30 00:01:11,505 --> 00:01:12,005 orthopedic 31 00:01:12,385 --> 00:01:12,885 platforms. 32 00:01:13,825 --> 00:01:16,645 Doctor Vaccaro, we're so happy to have you. 33 00:01:17,825 --> 00:01:18,885 So to start, 34 00:01:19,185 --> 00:01:20,564 I'll give you the opportunity 35 00:01:20,944 --> 00:01:23,780 to introduce yourself and also share a bit 36 00:01:23,780 --> 00:01:24,760 about your role. 37 00:01:25,540 --> 00:01:28,760 Sure. Sure. I am a professor of orthopedic 38 00:01:28,819 --> 00:01:29,879 surgery and neurosurgery. 39 00:01:30,260 --> 00:01:32,120 I'm the chairman of the department of orthopedic 40 00:01:32,340 --> 00:01:35,239 surgery at Thomas Jefferson University and the Sydney 41 00:01:35,924 --> 00:01:37,144 Kimmel Medical Center, 42 00:01:37,604 --> 00:01:39,784 and I'm the president of the Rothman Institute. 43 00:01:40,484 --> 00:01:42,564 And my role at Jefferson in terms of 44 00:01:42,564 --> 00:01:44,984 my clinical responsibilities is that, 45 00:01:45,924 --> 00:01:47,604 one of the many spine surgeons, and we 46 00:01:47,604 --> 00:01:49,700 have a great bunch of guys here 47 00:01:50,159 --> 00:01:52,099 that do research, we teach, 48 00:01:52,479 --> 00:01:55,359 and we do spinal care. And we serve 49 00:01:55,359 --> 00:01:58,739 the Southeastern Pennsylvania community, Northern Delaware, 50 00:01:59,519 --> 00:02:00,579 Southern New Jersey, 51 00:02:01,495 --> 00:02:03,575 and those that wanna travel far and near 52 00:02:03,575 --> 00:02:05,814 to to have service to Rothman Institute. So 53 00:02:05,814 --> 00:02:08,055 that that's my current role at the present 54 00:02:08,055 --> 00:02:09,835 time. Mhmm. Awesome. 55 00:02:10,534 --> 00:02:13,014 Well, with that, we'll we'll dive right into 56 00:02:13,014 --> 00:02:13,514 it. 57 00:02:14,229 --> 00:02:16,789 Obviously, we're coming upon a a new year 58 00:02:16,789 --> 00:02:20,569 here. So as you look ahead to 2026, 59 00:02:20,629 --> 00:02:22,709 can you talk a little bit about just 60 00:02:22,709 --> 00:02:24,409 what's top of mind for you, 61 00:02:25,269 --> 00:02:26,810 what some of those opportunities 62 00:02:27,189 --> 00:02:29,955 and and headwinds that you're looking out for 63 00:02:29,955 --> 00:02:30,455 are? 64 00:02:30,995 --> 00:02:31,735 Sure. So 65 00:02:32,275 --> 00:02:33,495 I think there's a battle 66 00:02:34,034 --> 00:02:34,534 for 67 00:02:35,074 --> 00:02:38,514 top notch orthopedic providers, and that battle is 68 00:02:38,514 --> 00:02:39,014 between 69 00:02:39,394 --> 00:02:40,294 private practice, 70 00:02:40,674 --> 00:02:41,174 multispecialty 71 00:02:41,634 --> 00:02:42,134 groups, 72 00:02:43,039 --> 00:02:45,139 hospital systems, and private equity. 73 00:02:46,080 --> 00:02:48,719 So our job is to get those that 74 00:02:48,719 --> 00:02:50,819 are interested in being entrepreneurial, 75 00:02:51,759 --> 00:02:53,539 not interested in an employed model, 76 00:02:54,159 --> 00:02:56,474 who understands the concept of risk. I mean, 77 00:02:56,474 --> 00:02:58,495 if you join a health care system today, 78 00:02:58,875 --> 00:03:02,175 you basically join a risk free compensation model. 79 00:03:02,555 --> 00:03:03,375 Risk free. 80 00:03:03,914 --> 00:03:06,395 The more bricks you break, the more RVs 81 00:03:06,395 --> 00:03:08,250 you generate, the more you get paid. 82 00:03:09,689 --> 00:03:11,370 And I'm not sure that's in the best 83 00:03:11,370 --> 00:03:13,370 interest of the patient or the best interest 84 00:03:13,370 --> 00:03:14,270 of the provider 85 00:03:14,650 --> 00:03:16,189 itself or the physician. 86 00:03:16,810 --> 00:03:19,949 So we try to give doctors the opportunity 87 00:03:20,414 --> 00:03:22,674 to be innovative in the care they provide, 88 00:03:23,454 --> 00:03:26,094 to have the flexibility and autonomy they need, 89 00:03:26,094 --> 00:03:27,555 and that's what represents 90 00:03:28,014 --> 00:03:30,435 private practice. So that's my opportunity. 91 00:03:31,775 --> 00:03:33,794 Another opportunity is the ability 92 00:03:34,260 --> 00:03:34,919 outside of 93 00:03:35,300 --> 00:03:36,919 a hospital employed system 94 00:03:37,620 --> 00:03:40,900 to have ownership of passive income sources, I 95 00:03:40,900 --> 00:03:42,120 mean, such as facilities, 96 00:03:42,900 --> 00:03:44,680 ASCs, specialty hospitals, 97 00:03:45,540 --> 00:03:48,040 ancillary lines. And there's so many different creative, 98 00:03:48,525 --> 00:03:50,605 productive ancillary lines all the way up up 99 00:03:50,605 --> 00:03:53,485 until concierge medicine that you can provide. And 100 00:03:53,485 --> 00:03:55,885 these are things that the employee model really 101 00:03:55,885 --> 00:03:57,344 does not allow the individual 102 00:03:57,645 --> 00:04:00,444 surgeons to aid, leave the rewards of, or 103 00:04:00,444 --> 00:04:01,185 be incentivized 104 00:04:01,485 --> 00:04:03,264 by. So I think that's 105 00:04:03,580 --> 00:04:04,959 something that we have to do. 106 00:04:05,340 --> 00:04:07,340 Another one is we have to sort of 107 00:04:07,340 --> 00:04:09,580 establish to make sure everyone works up to 108 00:04:09,580 --> 00:04:12,780 whatever their productivity standards are. So have everyone 109 00:04:12,780 --> 00:04:14,459 in our group work to the level of 110 00:04:14,459 --> 00:04:16,735 their license. If you're a PA and you're 111 00:04:16,735 --> 00:04:18,654 licensed to do certain things in my group, 112 00:04:18,654 --> 00:04:20,334 you should be doing those things. You shouldn't 113 00:04:20,334 --> 00:04:22,495 be relegated to a medical assistant. You shouldn't 114 00:04:22,495 --> 00:04:24,834 be relegated to a 115 00:04:25,214 --> 00:04:27,694 secretarial role. You should actually be out there 116 00:04:27,694 --> 00:04:29,214 doing what you need to do, and we 117 00:04:29,214 --> 00:04:31,699 try to maximize everyone's schedule. I mean, if 118 00:04:31,699 --> 00:04:33,699 you if you wanna be part time teaching, 119 00:04:33,699 --> 00:04:35,620 part time research, that's fine. But the times 120 00:04:35,620 --> 00:04:37,460 that you have allocated to these roles, we 121 00:04:37,460 --> 00:04:39,860 wanna make sure that you're efficient and you 122 00:04:39,860 --> 00:04:41,220 get things done. And we have to make 123 00:04:41,220 --> 00:04:43,319 it so you can be efficient. 124 00:04:43,780 --> 00:04:45,860 And then the last opportunity, I think, is 125 00:04:45,860 --> 00:04:46,360 really 126 00:04:46,904 --> 00:04:48,284 taking advantage of 127 00:04:48,584 --> 00:04:51,324 advanced technologies. Now I hate to say the 128 00:04:51,625 --> 00:04:55,224 buzzword agentic AI, but that's the buzzword now 129 00:04:55,224 --> 00:04:57,084 because I use it literally 130 00:04:57,784 --> 00:05:00,669 multiple times every day in everything I use. 131 00:05:00,669 --> 00:05:02,529 And not only in the business side 132 00:05:02,990 --> 00:05:05,149 to decrease employment costs, but I also use 133 00:05:05,149 --> 00:05:06,909 it in the operating room. I use robotics. 134 00:05:06,909 --> 00:05:09,949 So we're using advanced technologies to not only 135 00:05:09,949 --> 00:05:10,930 make surgery 136 00:05:11,389 --> 00:05:11,889 safer, 137 00:05:12,495 --> 00:05:14,035 more accurate, more precise, 138 00:05:14,574 --> 00:05:15,634 but more reproducible. 139 00:05:16,014 --> 00:05:17,855 These are the put in education from wrongs 140 00:05:17,855 --> 00:05:19,074 also. But also 141 00:05:19,455 --> 00:05:21,314 in terms of our business, you know, 142 00:05:21,774 --> 00:05:22,274 responding 143 00:05:22,814 --> 00:05:24,194 when we get our 144 00:05:24,669 --> 00:05:27,949 submissions for surgeries rejected by the insurance companies, 145 00:05:27,949 --> 00:05:30,289 immediately responding, saying, you know, here's the information, 146 00:05:30,990 --> 00:05:32,449 any type of appeal process, 147 00:05:32,829 --> 00:05:34,370 making sure we follow 148 00:05:34,909 --> 00:05:37,615 what the patients require in terms of the 149 00:05:37,615 --> 00:05:39,615 different offices we have, make sure we're full, 150 00:05:39,615 --> 00:05:42,095 make sure we're maximizing our staff. So that 151 00:05:42,095 --> 00:05:43,615 is what I think is the best in 152 00:05:43,615 --> 00:05:44,834 terms of our opportunities. 153 00:05:45,615 --> 00:05:46,834 In terms of our headwinds, 154 00:05:47,214 --> 00:05:49,375 that that's a challenging thing. The the biggest 155 00:05:49,375 --> 00:05:50,995 problem we have as providers 156 00:05:51,774 --> 00:05:54,350 is that we have to deal with prior 157 00:05:54,350 --> 00:05:55,169 authorization by 158 00:05:56,110 --> 00:05:57,009 those individuals 159 00:05:58,110 --> 00:06:01,009 not educated in the fields that they oversee. 160 00:06:01,709 --> 00:06:03,649 Those that do the prior authorizations 161 00:06:04,589 --> 00:06:07,310 abiding by certain clinical practice guidelines that don't 162 00:06:07,310 --> 00:06:10,044 really take in to consideration the individual patient. 163 00:06:10,044 --> 00:06:11,805 And sometimes, you have to think out of 164 00:06:11,805 --> 00:06:12,464 the box 165 00:06:12,845 --> 00:06:14,845 because at times, it may lead to worse 166 00:06:14,845 --> 00:06:16,284 patient care and things that are not in 167 00:06:16,284 --> 00:06:17,344 the patient's interest. 168 00:06:17,805 --> 00:06:20,524 And we're constantly being inundated by denials and 169 00:06:20,524 --> 00:06:23,069 policy changes. You you the the recent insurance 170 00:06:23,149 --> 00:06:25,089 companies that decided on their own to downcode 171 00:06:25,389 --> 00:06:27,889 CPT codes from level four to level three, 172 00:06:28,110 --> 00:06:29,550 these are the things that we have to 173 00:06:29,550 --> 00:06:31,790 do. And we go through, you know, a 174 00:06:31,790 --> 00:06:34,290 a periodic process, payer contract renewals, 175 00:06:34,750 --> 00:06:37,550 and sort of letting the world know that 176 00:06:37,550 --> 00:06:38,290 every day, 177 00:06:39,044 --> 00:06:39,544 my 178 00:06:39,845 --> 00:06:41,845 overhead costs go up. We have to deal 179 00:06:41,845 --> 00:06:43,204 with inflation, and we have to deal with 180 00:06:43,204 --> 00:06:44,104 the cost of capital, 181 00:06:44,644 --> 00:06:45,144 salaries, 182 00:06:45,524 --> 00:06:48,164 staffing. That doesn't get cheaper every year, so 183 00:06:48,164 --> 00:06:50,084 it doesn't make any sense that reimbursement can 184 00:06:50,084 --> 00:06:51,444 go down every year. So we have to 185 00:06:51,444 --> 00:06:52,664 come up with some consistent, 186 00:06:53,439 --> 00:06:55,680 methodology to make sure that both the insurance 187 00:06:55,680 --> 00:06:58,579 company, the patient, the government, and the physician 188 00:06:58,639 --> 00:06:59,300 are protected 189 00:06:59,680 --> 00:07:00,480 in terms of, 190 00:07:00,879 --> 00:07:01,379 maximizing 191 00:07:02,000 --> 00:07:02,500 whatever, 192 00:07:02,879 --> 00:07:04,819 limited dollars are available for everybody. 193 00:07:05,199 --> 00:07:05,600 And then, 194 00:07:06,634 --> 00:07:08,014 we have to look closely 195 00:07:08,714 --> 00:07:11,675 at our partners. We we we have multiple 196 00:07:11,675 --> 00:07:13,435 health care partners. If one of our health 197 00:07:13,435 --> 00:07:16,235 care partners has a disagreement with insurance company 198 00:07:16,235 --> 00:07:18,235 and decides at the last minute, I'm not 199 00:07:18,235 --> 00:07:20,634 gonna take this particular insurance, what affects our 200 00:07:20,634 --> 00:07:22,300 patients is private practice, so we have to 201 00:07:22,300 --> 00:07:22,879 deal with 202 00:07:23,339 --> 00:07:24,459 that. And then we have to deal with 203 00:07:24,459 --> 00:07:27,019 the inflationary pressures that everyone has to deal 204 00:07:27,019 --> 00:07:28,540 with at the present time. I mean, the 205 00:07:28,620 --> 00:07:30,000 I mean, the cost of 206 00:07:30,379 --> 00:07:32,000 goods are going up. Mhmm. 207 00:07:32,699 --> 00:07:35,019 My secretary will support my nursing staff. My 208 00:07:35,019 --> 00:07:37,365 medical assistant's going up. And how do I 209 00:07:37,365 --> 00:07:38,824 provide adequate care 210 00:07:39,365 --> 00:07:41,944 when every year due to congressional 211 00:07:42,805 --> 00:07:43,305 mandates, 212 00:07:43,845 --> 00:07:45,685 reimbursement goes down? It just doesn't make any 213 00:07:45,685 --> 00:07:47,225 sense. So we have to fight that. 214 00:07:47,925 --> 00:07:50,480 Yeah. Great points there. I think you you 215 00:07:50,480 --> 00:07:52,899 mentioned a ton of what is on, 216 00:07:53,199 --> 00:07:55,519 you know, leaders across the board's mind in 217 00:07:55,519 --> 00:07:56,580 terms of orthopedic, 218 00:07:57,519 --> 00:07:58,180 you know, 219 00:07:58,480 --> 00:07:58,980 opportunities 220 00:07:59,519 --> 00:08:01,939 in the next year and also the headwinds. 221 00:08:02,000 --> 00:08:02,819 And I think 222 00:08:03,245 --> 00:08:05,485 the first time we talked, I think you 223 00:08:05,485 --> 00:08:06,225 did mention 224 00:08:06,605 --> 00:08:08,464 that idea of prior authorization 225 00:08:08,925 --> 00:08:10,625 and claims being denied, 226 00:08:11,324 --> 00:08:13,805 because a lot of these insurance companies are 227 00:08:13,805 --> 00:08:14,705 using AI, 228 00:08:15,564 --> 00:08:18,089 and things like that. So we're definitely still 229 00:08:18,089 --> 00:08:19,149 seeing that continue 230 00:08:19,689 --> 00:08:20,350 to be, 231 00:08:20,970 --> 00:08:23,069 a problem, and it's definitely something 232 00:08:23,689 --> 00:08:25,769 that leaders like yourself are gonna have to 233 00:08:25,769 --> 00:08:27,550 navigate into the new year. 234 00:08:28,089 --> 00:08:31,949 I'm wondering, doctor Vaquero, from a clinical standpoint, 235 00:08:32,865 --> 00:08:33,605 which innovations 236 00:08:34,144 --> 00:08:36,085 or care models do you think 237 00:08:36,705 --> 00:08:37,365 will meaningfully 238 00:08:37,745 --> 00:08:41,924 shift how orthopedic care is delivered in 2026? 239 00:08:42,865 --> 00:08:44,725 So if you look closely 240 00:08:45,170 --> 00:08:47,730 at what we provide patients anywhere from more 241 00:08:47,730 --> 00:08:48,230 surgical 242 00:08:49,250 --> 00:08:52,070 skills to nonoperative care such as injections, 243 00:08:52,529 --> 00:08:53,430 stem cells, 244 00:08:54,529 --> 00:08:57,269 hyaluronic acid injections for knees, bracing, 245 00:08:58,284 --> 00:09:00,924 If we as orthopedic surgeons can sort of 246 00:09:00,924 --> 00:09:02,865 control that business aspect 247 00:09:03,404 --> 00:09:06,304 and take it away from high cost vendors 248 00:09:07,004 --> 00:09:09,004 and bring that in house, like, all the 249 00:09:09,004 --> 00:09:10,544 different ancillors you see 250 00:09:10,970 --> 00:09:13,290 that don't pose a direct conflict. Like, you 251 00:09:13,290 --> 00:09:14,910 you never wanna provide an ancillary 252 00:09:15,370 --> 00:09:17,389 where you can increase the cost of care. 253 00:09:17,450 --> 00:09:19,210 If it's something that you have to prescribe 254 00:09:19,210 --> 00:09:20,029 to a patient, 255 00:09:20,570 --> 00:09:21,870 why can't we be 256 00:09:22,490 --> 00:09:24,554 the owner of that business 257 00:09:24,855 --> 00:09:27,014 so then we can not only dramatically drop 258 00:09:27,014 --> 00:09:27,675 the cost, 259 00:09:28,215 --> 00:09:29,735 but also provide what we think is best 260 00:09:29,735 --> 00:09:31,115 in class? I'll give you an example. 261 00:09:31,495 --> 00:09:34,054 When you order a brace from a hospital, 262 00:09:34,054 --> 00:09:35,975 an orthotist, it may cost a thousand dollars, 263 00:09:35,975 --> 00:09:37,495 and that patient may say, well, listen. Let 264 00:09:37,495 --> 00:09:39,509 me go to Amazon online and get it 265 00:09:39,509 --> 00:09:40,009 cheaper. 266 00:09:40,389 --> 00:09:42,549 So creating orthopedic tours where you could say, 267 00:09:42,549 --> 00:09:43,910 listen. We can we can do better than 268 00:09:43,910 --> 00:09:45,509 that. We can drop we can be the 269 00:09:45,509 --> 00:09:46,009 manufacturer 270 00:09:46,470 --> 00:09:49,190 and the distributor, and we can provide that 271 00:09:49,190 --> 00:09:50,970 service and use technologies 272 00:09:51,865 --> 00:09:53,785 that may support that. Like, you you use 273 00:09:53,785 --> 00:09:54,684 three d printing 274 00:09:54,985 --> 00:09:56,585 to create things that we may need to 275 00:09:56,585 --> 00:09:58,745 brace a patient, which be a a great 276 00:09:58,745 --> 00:10:00,845 idea. So that that's an opportunity 277 00:10:01,305 --> 00:10:04,024 that we can, you know, strive to decrease 278 00:10:04,024 --> 00:10:06,269 the cost of care. I think another innovation 279 00:10:06,269 --> 00:10:08,429 in the care model is introducing the concept 280 00:10:08,429 --> 00:10:10,110 that the medical doctors came up with, and 281 00:10:10,110 --> 00:10:11,649 that's concierge medicine. 282 00:10:12,110 --> 00:10:14,370 I mean, it is so frustrating now 283 00:10:14,910 --> 00:10:17,870 to guide someone into an integrated health care 284 00:10:17,870 --> 00:10:18,370 system, 285 00:10:19,184 --> 00:10:20,945 and why can't we make that easy for 286 00:10:20,945 --> 00:10:23,424 MSK care? You know, just say that someone 287 00:10:23,424 --> 00:10:26,065 comes in, we can organize their imaging studies. 288 00:10:26,065 --> 00:10:28,144 We can organize their nonoperative care. We can 289 00:10:28,144 --> 00:10:29,745 do their physical therapy. We can do their 290 00:10:29,745 --> 00:10:30,245 injections, 291 00:10:30,625 --> 00:10:32,059 and then we can take them to the 292 00:10:32,059 --> 00:10:34,460 journey if they require surgery, make sure that 293 00:10:34,460 --> 00:10:36,379 we have support for their family, maybe a 294 00:10:36,379 --> 00:10:37,759 meal service, maybe transportation. 295 00:10:38,220 --> 00:10:41,179 After that, we give them premium opportunities to 296 00:10:41,179 --> 00:10:42,620 come in when they need to be seen 297 00:10:42,620 --> 00:10:44,139 by someone and not to not to roll 298 00:10:44,139 --> 00:10:45,914 their eyes and have a headache. I I 299 00:10:45,914 --> 00:10:47,695 just spoke to one of my partners today 300 00:10:47,914 --> 00:10:50,475 who presented Grand Rounds who who discussed his 301 00:10:50,475 --> 00:10:52,815 journey after brain surgery, and he was 302 00:10:53,195 --> 00:10:54,014 so frustrating 303 00:10:54,955 --> 00:10:57,115 to see the surprise billing, this and that. 304 00:10:57,115 --> 00:10:59,355 Why can't we facilitate that for the patient 305 00:10:59,674 --> 00:11:01,375 for those patients that had the ability, 306 00:11:01,860 --> 00:11:03,379 to pay extra so we can make their 307 00:11:03,379 --> 00:11:04,899 lives so much more comfortable. So I think 308 00:11:04,899 --> 00:11:07,139 that's those are the innovative things we can 309 00:11:07,139 --> 00:11:08,740 do in terms of shifting the care model. 310 00:11:08,740 --> 00:11:11,379 We've we've already moved to bundle payments. We 311 00:11:11,379 --> 00:11:13,159 went through that exercise. We realized 312 00:11:13,460 --> 00:11:15,059 what costs too much and what doesn't cost 313 00:11:15,059 --> 00:11:17,195 too much, but bundle payments were really a 314 00:11:17,195 --> 00:11:18,715 race to the bottom. And once you reach 315 00:11:18,715 --> 00:11:20,554 the bottom of you can't squeeze any more 316 00:11:20,554 --> 00:11:23,034 juice out of that orange. Now we're looking 317 00:11:23,034 --> 00:11:24,634 for ways of saying, okay. This is the 318 00:11:24,634 --> 00:11:27,514 bottom line cost, and those people that can 319 00:11:27,514 --> 00:11:29,835 afford to pay more may have the ability 320 00:11:29,835 --> 00:11:31,914 to have less frustration. They everyone gets the 321 00:11:31,914 --> 00:11:34,159 same quality of care, but less frustrations in 322 00:11:34,159 --> 00:11:35,779 terms of navigating that care. 323 00:11:36,319 --> 00:11:38,100 Super important points there. 324 00:11:39,039 --> 00:11:41,440 And it's a phrase that I often hear 325 00:11:41,440 --> 00:11:44,965 talking to orthopedic surgeons like yourself is the 326 00:11:44,965 --> 00:11:46,024 race to the bottom. 327 00:11:48,245 --> 00:11:50,345 And, yeah, I mean, I think that, 328 00:11:51,445 --> 00:11:54,504 obviously, the innovations that you just talked about 329 00:11:54,644 --> 00:11:56,644 would be, you know, great, and I think 330 00:11:56,644 --> 00:11:57,144 that 331 00:11:57,740 --> 00:11:58,620 2026 332 00:11:58,620 --> 00:12:00,379 is really gonna be the year of putting 333 00:12:00,379 --> 00:12:03,360 those things to practice. Right? Everyone was excited 334 00:12:03,419 --> 00:12:05,820 about AI and all this new technology and 335 00:12:05,820 --> 00:12:06,720 stuff in 336 00:12:07,100 --> 00:12:07,980 2025, 337 00:12:07,980 --> 00:12:09,659 but now it's time to to get to 338 00:12:09,659 --> 00:12:10,159 work. 339 00:12:10,779 --> 00:12:11,279 So 340 00:12:11,834 --> 00:12:13,294 super great stuff there. 341 00:12:13,834 --> 00:12:18,654 Obviously, the orthopedic workforce is continuing to evolve 342 00:12:18,714 --> 00:12:19,615 from surgeons 343 00:12:20,475 --> 00:12:21,375 to APPs 344 00:12:21,754 --> 00:12:23,134 to care teams. 345 00:12:23,879 --> 00:12:25,340 What are you prioritizing, 346 00:12:26,200 --> 00:12:27,480 in 2026 347 00:12:27,480 --> 00:12:29,179 to support your teams and 348 00:12:29,480 --> 00:12:30,940 really help them thrive? 349 00:12:31,879 --> 00:12:33,559 Well, then that's a great question because I 350 00:12:33,559 --> 00:12:35,799 think, really, as we expand our care, we 351 00:12:35,799 --> 00:12:37,259 have to do it through APPs. 352 00:12:37,835 --> 00:12:39,674 And they're such an important part of the 353 00:12:39,674 --> 00:12:42,394 provider network. They interface with our patients. They 354 00:12:42,394 --> 00:12:44,235 see patients in clinic. They have their own 355 00:12:44,235 --> 00:12:45,134 office hours. 356 00:12:45,754 --> 00:12:48,014 They they select those that may need to 357 00:12:48,235 --> 00:12:48,735 experience 358 00:12:49,035 --> 00:12:50,654 higher level of care, IEC, 359 00:12:51,115 --> 00:12:53,620 a surgeon, so they're fantastic. And then a 360 00:12:53,620 --> 00:12:55,540 a lot of physicians have APPs that come 361 00:12:55,540 --> 00:12:58,440 to the operating room. Now I'm an academic 362 00:12:58,580 --> 00:13:00,740 professor, so I don't have a PA in 363 00:13:00,740 --> 00:13:03,540 my operating room. So every two months, I 364 00:13:03,540 --> 00:13:06,105 have a different chief resident, and every three 365 00:13:06,105 --> 00:13:08,425 months, I have a different spine fellow. So 366 00:13:08,425 --> 00:13:10,425 I go through the same routine where I 367 00:13:10,425 --> 00:13:12,425 have to teach them how to position a 368 00:13:12,425 --> 00:13:14,425 patient, how to do this or that, how 369 00:13:14,425 --> 00:13:16,185 to close the patient, stuff like that. If 370 00:13:16,185 --> 00:13:17,325 you have an APP 371 00:13:17,865 --> 00:13:20,250 or physiatrists that you work with, once they 372 00:13:20,250 --> 00:13:20,750 learn 373 00:13:21,529 --> 00:13:23,129 it and they they're loyal and they stick 374 00:13:23,129 --> 00:13:24,750 with you for a long period of time, 375 00:13:24,970 --> 00:13:26,029 it dramatically 376 00:13:26,490 --> 00:13:28,590 decrease decreases your anxiety, 377 00:13:29,050 --> 00:13:30,889 the headaches. You don't have to think twice 378 00:13:30,889 --> 00:13:32,904 about it. It's like having a mirror image 379 00:13:32,904 --> 00:13:34,665 of yourself in the Operating Room helping you 380 00:13:34,665 --> 00:13:36,825 with all the procedures. So we have to 381 00:13:36,825 --> 00:13:39,785 continue to get people motivated and train the 382 00:13:39,785 --> 00:13:41,945 extenders. Now the extenders can also reach out 383 00:13:41,945 --> 00:13:44,504 to geographic territories that we don't have the 384 00:13:44,504 --> 00:13:46,764 ability to be in. So, again, having extenders 385 00:13:46,904 --> 00:13:47,725 go out to 386 00:13:48,120 --> 00:13:50,200 geographic regions that we wanna have our tentacles 387 00:13:50,200 --> 00:13:52,440 in as the Rothman Institute and but have 388 00:13:52,440 --> 00:13:54,759 them meet patients that want our care. And 389 00:13:54,759 --> 00:13:56,600 if we need to speak to that patient 390 00:13:56,600 --> 00:13:58,220 while they're seeing a PA, use telemedicine 391 00:13:58,679 --> 00:14:00,120 and if they need a higher level of 392 00:14:00,120 --> 00:14:00,620 care, 393 00:14:01,424 --> 00:14:03,264 see us. So in order for us to 394 00:14:03,264 --> 00:14:04,404 scale our operations, 395 00:14:05,024 --> 00:14:06,705 we have to figure out what the ratio 396 00:14:06,705 --> 00:14:09,125 of those providers are, ratios of 397 00:14:09,585 --> 00:14:10,085 MAs, 398 00:14:10,545 --> 00:14:11,045 PAs, 399 00:14:11,424 --> 00:14:14,945 and physicians, and what supports a growing practice. 400 00:14:14,945 --> 00:14:15,959 So we analyze 401 00:14:16,259 --> 00:14:18,259 the days out to see a PA and 402 00:14:18,259 --> 00:14:20,120 the days out to see a a surgeon, 403 00:14:20,179 --> 00:14:21,620 and then we look at those that need 404 00:14:21,620 --> 00:14:23,379 to see a surgeon. And if those days 405 00:14:23,379 --> 00:14:25,059 go above a certain number, we say, okay. 406 00:14:25,059 --> 00:14:26,580 We we need more PAs or we need 407 00:14:26,580 --> 00:14:28,740 more surgeons. So it helps us build our 408 00:14:28,740 --> 00:14:31,644 workforce appropriately, and it helps us build our 409 00:14:31,644 --> 00:14:32,464 PA support. 410 00:14:32,764 --> 00:14:34,445 We also have our PAs do things a 411 00:14:34,445 --> 00:14:36,144 lot of the nonoperative care. 412 00:14:36,684 --> 00:14:38,524 So we we as we build a strong 413 00:14:38,524 --> 00:14:42,144 nonoperative physician force such as nonoperative sports medicine, 414 00:14:42,365 --> 00:14:42,865 physiatrists, 415 00:14:43,725 --> 00:14:46,284 and so forth, they need support also from 416 00:14:46,284 --> 00:14:48,450 PAs to set patients up for injections and 417 00:14:48,450 --> 00:14:50,769 so forth. And so we we really wanna 418 00:14:50,769 --> 00:14:52,790 make sure we invest in those APPs, 419 00:14:53,570 --> 00:14:55,910 so we can support our professional growth. 420 00:14:56,529 --> 00:14:58,129 Yeah. I think I think that's such a 421 00:14:58,129 --> 00:14:59,429 big topic too, 422 00:15:00,304 --> 00:15:02,705 just across the board with orthopedics. I know 423 00:15:02,705 --> 00:15:05,024 I've, again, talked to a lot of different 424 00:15:05,024 --> 00:15:07,764 surgeons who have mentioned just the importance 425 00:15:08,225 --> 00:15:09,845 of APPs to, 426 00:15:10,144 --> 00:15:11,284 you know, your everyday 427 00:15:11,585 --> 00:15:12,085 work. 428 00:15:13,345 --> 00:15:16,100 So really great great points there. 429 00:15:16,639 --> 00:15:18,720 You kind of got into this that Rothman 430 00:15:18,720 --> 00:15:21,200 has sort of tentacles in different places, which 431 00:15:21,200 --> 00:15:23,360 is a really fun way to put it, 432 00:15:23,360 --> 00:15:26,660 but Rothman really does have such a broad 433 00:15:27,284 --> 00:15:27,784 footprint. 434 00:15:29,044 --> 00:15:31,065 What changes or investments 435 00:15:31,524 --> 00:15:33,865 are you planning to make next year? 436 00:15:34,804 --> 00:15:36,964 K. So first of all, I'm a big 437 00:15:36,964 --> 00:15:39,044 supporter of organic growth. So let me tell 438 00:15:39,044 --> 00:15:41,865 you what that is. So we, years ago, 439 00:15:42,159 --> 00:15:44,399 began to associate with other practices. We brought 440 00:15:44,399 --> 00:15:45,860 them into the Rothman Institute. 441 00:15:46,240 --> 00:15:48,019 And I always say culture 442 00:15:48,720 --> 00:15:51,679 trumps strategy any day of the week. Mhmm. 443 00:15:51,679 --> 00:15:53,919 And I we train we train. I train 444 00:15:53,919 --> 00:15:56,399 four spline fellows a year. We train 36 445 00:15:56,399 --> 00:15:56,899 residents, 446 00:15:57,245 --> 00:15:59,105 all the different specialties of fellows. 447 00:15:59,565 --> 00:16:01,884 And my best partners are those that came 448 00:16:01,884 --> 00:16:03,024 out of our 449 00:16:03,404 --> 00:16:06,445 training program that know exactly how we think, 450 00:16:06,445 --> 00:16:08,684 not only in the operating room, but how 451 00:16:08,684 --> 00:16:11,139 we think in terms of a team. Mhmm. 452 00:16:11,139 --> 00:16:12,580 And we have a great we're sort of 453 00:16:12,580 --> 00:16:14,580 a high performing team. You have people that 454 00:16:14,580 --> 00:16:17,459 get together. There's pseudo teams, good teams. There's 455 00:16:17,459 --> 00:16:20,339 high functioning teams. So they watch how we 456 00:16:20,339 --> 00:16:22,100 how we perform as a high functioning team, 457 00:16:22,100 --> 00:16:24,179 and, plus, they respect their professors and their 458 00:16:24,179 --> 00:16:24,679 teachers. 459 00:16:25,004 --> 00:16:27,404 So we wanna invest in additional providers, number 460 00:16:27,404 --> 00:16:29,725 one. Then we also wanna make sure that 461 00:16:29,725 --> 00:16:31,345 we have the appropriate footprint 462 00:16:31,804 --> 00:16:34,865 and make sure that we expand strategically 463 00:16:35,165 --> 00:16:36,705 in the right areas. And, again, 464 00:16:37,085 --> 00:16:40,919 focus on technologies and and forecasting reports and 465 00:16:41,139 --> 00:16:42,899 and population growth and stuff like that and 466 00:16:42,899 --> 00:16:44,659 use all the old tools available to say 467 00:16:44,659 --> 00:16:46,340 where we have to have patients, where we 468 00:16:46,340 --> 00:16:48,340 have to have providers grow. And then we 469 00:16:48,340 --> 00:16:51,379 want to geographically expand. Now that as I 470 00:16:51,379 --> 00:16:53,460 said, we grow a core market. But if 471 00:16:53,460 --> 00:16:54,600 we decide to do 472 00:16:55,024 --> 00:16:56,304 and get together with a group that has 473 00:16:56,304 --> 00:16:58,465 a similar value systems to Rothman Institute, we 474 00:16:58,465 --> 00:17:01,024 publish our mission statement. We publish our values. 475 00:17:01,024 --> 00:17:02,465 We publish all that, and we make it 476 00:17:02,465 --> 00:17:04,545 public what we plan to do. We're here 477 00:17:04,545 --> 00:17:08,085 for not only clinical excellence, but teaching, research, 478 00:17:08,144 --> 00:17:08,724 and education. 479 00:17:09,329 --> 00:17:11,089 So we wanna make sure that we team 480 00:17:11,089 --> 00:17:13,829 up with like minded people, but leave economies 481 00:17:13,890 --> 00:17:15,169 local. So if we team up with a 482 00:17:15,169 --> 00:17:17,650 group in Ohio, our job isn't to manage 483 00:17:17,650 --> 00:17:19,730 the back office. Our our job is to 484 00:17:19,730 --> 00:17:22,130 scale those resources that make their back office 485 00:17:22,130 --> 00:17:22,630 effective, 486 00:17:23,105 --> 00:17:25,585 but contracting state specific. So they're gonna have 487 00:17:25,585 --> 00:17:27,585 different reimbursement models. They're gonna have different workman's 488 00:17:27,585 --> 00:17:29,105 comp laws and stuff like that. We can't 489 00:17:29,105 --> 00:17:30,785 get into the weeds with that. But we 490 00:17:30,785 --> 00:17:32,384 can get into the weeds when it comes 491 00:17:32,384 --> 00:17:32,884 to 492 00:17:33,345 --> 00:17:36,065 how to scale, how to use the resources 493 00:17:36,065 --> 00:17:38,325 that we have, how to negotiate insurance contracts, 494 00:17:38,549 --> 00:17:40,309 how to use the expertise that we've gathered 495 00:17:40,309 --> 00:17:42,390 over time. So I think those are the 496 00:17:42,390 --> 00:17:44,549 things that, we have to do and invest 497 00:17:44,549 --> 00:17:47,850 in the future. Mhmm. And technology, technology, technology 498 00:17:47,910 --> 00:17:49,450 is where it's at. Mhmm. 499 00:17:49,990 --> 00:17:53,195 Yep. Absolutely. I think, again, another common theme 500 00:17:53,195 --> 00:17:55,994 is technology. And, again, I'm gonna say it 501 00:17:55,994 --> 00:17:56,475 again, 502 00:17:56,875 --> 00:17:58,315 but 2026 503 00:17:58,315 --> 00:18:00,394 is really gonna be the time to get 504 00:18:00,394 --> 00:18:01,055 to work, 505 00:18:01,755 --> 00:18:02,255 and 506 00:18:02,795 --> 00:18:03,855 use that technology, 507 00:18:04,235 --> 00:18:06,654 like you've been sort of explaining, to really 508 00:18:07,049 --> 00:18:07,549 thrive. 509 00:18:09,210 --> 00:18:11,049 And I really like what you said too 510 00:18:11,049 --> 00:18:14,509 just about culture and and culture really trumping 511 00:18:15,049 --> 00:18:16,809 strategy at the end of the day, and 512 00:18:16,809 --> 00:18:18,110 I think that's an important 513 00:18:18,890 --> 00:18:19,390 mindset 514 00:18:19,744 --> 00:18:22,164 to have not only in in your workspace, 515 00:18:22,384 --> 00:18:23,765 but in any workspace. 516 00:18:24,865 --> 00:18:27,265 Looking back now, we're gonna reflect a little 517 00:18:27,265 --> 00:18:30,484 bit. Looking back now on on 2025, 518 00:18:30,705 --> 00:18:33,125 what's one lesson or moment, 519 00:18:33,830 --> 00:18:37,509 that surprised you or reshaped your thinking as 520 00:18:37,509 --> 00:18:38,170 a leader? 521 00:18:39,109 --> 00:18:41,369 Okay. And this is is this everyone's problem 522 00:18:41,509 --> 00:18:42,730 in medicine today? 523 00:18:43,109 --> 00:18:44,730 And that's how crazy 524 00:18:45,670 --> 00:18:46,330 the malpractice 525 00:18:47,190 --> 00:18:48,890 situation is around the country. 526 00:18:49,304 --> 00:18:50,524 The nuclear verdicts 527 00:18:50,904 --> 00:18:53,865 Mhmm. Taking care of professional athletes that make 528 00:18:53,865 --> 00:18:54,984 $70,102 529 00:18:54,984 --> 00:18:56,044 $100,000,000 530 00:18:56,105 --> 00:18:57,004 and to 531 00:18:57,304 --> 00:18:59,164 go out and to treat these individuals 532 00:18:59,704 --> 00:19:01,865 with the best care you know how. And 533 00:19:01,865 --> 00:19:03,484 then if something goes wrong, 534 00:19:04,009 --> 00:19:06,409 have that particular risk that can close down 535 00:19:06,409 --> 00:19:07,069 an institution. 536 00:19:07,769 --> 00:19:09,849 There has to be, at the federal level 537 00:19:09,849 --> 00:19:12,250 and at the state level, target form that's 538 00:19:12,250 --> 00:19:12,750 sober 539 00:19:13,289 --> 00:19:16,684 that protects those that provide competent care. I'm 540 00:19:16,684 --> 00:19:18,365 not talking about negligent care. I'm talking about 541 00:19:18,365 --> 00:19:20,865 competent care. Because as you and I know, 542 00:19:21,244 --> 00:19:21,744 sometimes, 543 00:19:22,444 --> 00:19:24,525 actions are brought against physicians that do the 544 00:19:24,525 --> 00:19:26,204 right thing, but the patient may have a 545 00:19:26,204 --> 00:19:27,964 bad outcome. So we have to protect those 546 00:19:27,964 --> 00:19:29,804 doctors, and we can't leave it up to 547 00:19:29,804 --> 00:19:30,384 the whim 548 00:19:30,990 --> 00:19:33,230 of those that may not be educated in 549 00:19:33,230 --> 00:19:33,730 understanding 550 00:19:34,109 --> 00:19:35,710 how that care was delivered and what is 551 00:19:35,710 --> 00:19:37,890 the expected outcome. And I'm a big supporter 552 00:19:38,670 --> 00:19:40,210 of medical courtrooms, 553 00:19:41,470 --> 00:19:44,190 where these courtrooms are designed just like we 554 00:19:44,190 --> 00:19:45,069 have it for, 555 00:19:45,390 --> 00:19:46,690 arbitration for 556 00:19:47,125 --> 00:19:49,704 brokerage legal matters and and other more specialized 557 00:19:49,765 --> 00:19:50,265 courts, 558 00:19:50,724 --> 00:19:53,525 we we have to really, really, really protect 559 00:19:53,525 --> 00:19:55,365 the provider because there's only so much money 560 00:19:55,365 --> 00:19:57,365 that can go around. And if you on 561 00:19:57,365 --> 00:19:59,365 top of the fact that you're getting your 562 00:19:59,365 --> 00:20:00,664 reimbursement cut 563 00:20:01,169 --> 00:20:02,929 and you have to do more with less, 564 00:20:02,929 --> 00:20:04,629 and then on top of that, your malpractice 565 00:20:04,769 --> 00:20:06,929 cost goes up, and then there's a nuclear 566 00:20:06,929 --> 00:20:09,009 verdict I'm only focused on when there isn't 567 00:20:09,009 --> 00:20:09,509 negligence 568 00:20:10,210 --> 00:20:12,049 and there's a verdict against you. That can 569 00:20:12,049 --> 00:20:14,049 really affect all the patients in the community 570 00:20:14,049 --> 00:20:15,644 that require care, and then you have to 571 00:20:15,644 --> 00:20:18,125 close-up shop. So we've seen that happen in 572 00:20:18,125 --> 00:20:18,865 the high risk, 573 00:20:19,484 --> 00:20:21,404 specialties, and we have to protect against that. 574 00:20:21,404 --> 00:20:23,484 And I I think medical malpractice is all 575 00:20:23,484 --> 00:20:23,984 political. 576 00:20:24,285 --> 00:20:27,005 I say everyone's supportive. If if there's harm, 577 00:20:27,005 --> 00:20:28,845 patients have to be compensated in the setting 578 00:20:28,845 --> 00:20:30,684 of negligence, but that's not what I'm talking 579 00:20:30,684 --> 00:20:32,630 about. I'm I'm talking about the egregious amount 580 00:20:32,630 --> 00:20:34,970 of money that's spent on defensive medicine 581 00:20:35,429 --> 00:20:37,670 and on settlements and verdicts when there's no 582 00:20:37,670 --> 00:20:39,990 medical malpractice and there's no protection in some 583 00:20:39,990 --> 00:20:42,150 states, and it doesn't make any sense to 584 00:20:42,150 --> 00:20:42,650 me. 585 00:20:43,029 --> 00:20:45,315 So we have to protect against the financial 586 00:20:45,315 --> 00:20:47,815 risks. Another risk, again, in the legal realm 587 00:20:48,275 --> 00:20:48,775 is 588 00:20:49,154 --> 00:20:51,575 when people can come and, 589 00:20:52,994 --> 00:20:53,815 drop ransom 590 00:20:54,515 --> 00:20:55,015 viruses 591 00:20:55,394 --> 00:20:57,075 on your health care system that hold you 592 00:20:57,075 --> 00:20:59,414 hostage that happened at our health care system. 593 00:20:59,519 --> 00:21:01,680 And there again, you you do the best 594 00:21:01,680 --> 00:21:04,240 you can. You follow all the established rules 595 00:21:04,240 --> 00:21:06,180 on, you know, don't don't click on 596 00:21:06,559 --> 00:21:08,799 a email you don't recognize and do this 597 00:21:08,799 --> 00:21:11,220 or that. But these these people are sophisticated, 598 00:21:11,279 --> 00:21:13,934 and they use AI generated strategies to 599 00:21:14,335 --> 00:21:16,095 infect your computer. And then all of a 600 00:21:16,095 --> 00:21:17,375 sudden, you're locked out, and then you have 601 00:21:17,375 --> 00:21:18,975 to pay the price. So we need we 602 00:21:18,975 --> 00:21:21,855 need federal support for that and federal protection. 603 00:21:21,855 --> 00:21:24,434 So, we basically need the federal government 604 00:21:24,815 --> 00:21:26,835 to come out and help us and protect 605 00:21:26,975 --> 00:21:29,394 those that care for people. We were decimated 606 00:21:30,029 --> 00:21:32,930 in terms of a profession during the COVID 607 00:21:33,549 --> 00:21:35,630 while we gave our time and and our 608 00:21:35,630 --> 00:21:37,390 lives to take care of patients. So we 609 00:21:37,390 --> 00:21:38,910 we need to have that type of support 610 00:21:38,910 --> 00:21:40,750 from the government for these issues that we 611 00:21:40,750 --> 00:21:41,894 have no control over. 612 00:21:42,775 --> 00:21:43,275 Absolutely. 613 00:21:44,295 --> 00:21:45,755 Again, super important 614 00:21:46,535 --> 00:21:47,434 points there. 615 00:21:47,894 --> 00:21:50,795 And, doctor Pacquero, this has been an incredibly 616 00:21:51,494 --> 00:21:51,994 insightful 617 00:21:52,455 --> 00:21:54,934 conversation, and I wanna thank you again for 618 00:21:54,934 --> 00:21:55,434 sharing 619 00:21:55,920 --> 00:21:58,180 your perspective and leadership insights 620 00:21:58,480 --> 00:21:59,220 with us. 621 00:21:59,920 --> 00:22:02,019 That is all we have today. 622 00:22:02,559 --> 00:22:05,039 Pleasure to speak with you. Always a pleasure 623 00:22:05,039 --> 00:22:06,340 to speak with you too. 624 00:22:06,799 --> 00:22:09,317 Thank you so much for for joining us 625 00:22:09,317 --> 00:22:12,277 and offering valuable insights into the future of 626 00:22:12,277 --> 00:22:13,097 spine care, 627 00:22:13,557 --> 00:22:16,297 orthopedic innovation, and physician leadership.