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