1 00:00:00,080 --> 00:00:02,080 This is Carly Beam with Becker Spine and 2 00:00:02,080 --> 00:00:04,799 Orthopedics podcast. I'm thrilled to be joined today 3 00:00:04,799 --> 00:00:07,759 by doctor Alan Daniels. Doctor Daniels, thank you 4 00:00:07,759 --> 00:00:10,400 for joining us. Thanks for having me. So 5 00:00:10,400 --> 00:00:12,480 before we dive into our questions, I wanted 6 00:00:12,480 --> 00:00:14,934 you to just please introduce yourself and share 7 00:00:14,934 --> 00:00:16,234 a bit more about your background. 8 00:00:17,175 --> 00:00:19,175 Yeah. So I'm an orthopedic spine surgeon in 9 00:00:19,175 --> 00:00:21,274 Providence, Rhode Island at Brown University. 10 00:00:22,454 --> 00:00:24,535 I did my training here and and stayed 11 00:00:24,535 --> 00:00:26,535 on. And one of the main reasons was 12 00:00:26,535 --> 00:00:29,254 we have an organization called University Orthopedics, which 13 00:00:29,254 --> 00:00:31,710 is a private practice. It's a large orthopedic 14 00:00:31,710 --> 00:00:33,170 practice with 70 surgeons 15 00:00:33,789 --> 00:00:35,409 that basically is a 16 00:00:35,870 --> 00:00:37,229 center that owns, 17 00:00:37,789 --> 00:00:38,770 around real estate. 18 00:00:39,789 --> 00:00:43,010 We have ancillary services, and we have facilities 19 00:00:43,149 --> 00:00:45,414 all over the region. And it's just has 20 00:00:45,414 --> 00:00:47,414 been a very rewarding way to practice and 21 00:00:47,414 --> 00:00:49,034 that I get to, 22 00:00:50,134 --> 00:00:51,274 have a very 23 00:00:51,655 --> 00:00:52,155 fruitful, 24 00:00:52,614 --> 00:00:55,114 I'll say, private practice while I also 25 00:00:55,655 --> 00:00:56,795 do a lot of academics, 26 00:00:57,340 --> 00:00:59,740 teach residents, fellows, and work very closely with 27 00:00:59,740 --> 00:01:01,820 the university. So it's really a perfect mix 28 00:01:01,820 --> 00:01:02,479 for me. 29 00:01:03,100 --> 00:01:05,439 Definitely. And I'd love to hear, you know, 30 00:01:05,500 --> 00:01:07,599 what are the biggest advantages you've 31 00:01:08,060 --> 00:01:11,020 been seeing both working from a private practice 32 00:01:11,020 --> 00:01:11,520 perspective 33 00:01:11,825 --> 00:01:13,525 and then also in the academic setting? 34 00:01:15,105 --> 00:01:17,025 Well, you really nailed it on the head 35 00:01:17,025 --> 00:01:19,185 in that there are advantages to each, and 36 00:01:19,185 --> 00:01:20,865 that's why it's so nice being in a 37 00:01:20,865 --> 00:01:22,564 in a private academic environment. 38 00:01:23,025 --> 00:01:25,265 Mhmm. The advantages of private practice are that 39 00:01:25,265 --> 00:01:26,484 we have a lot of autonomy. 40 00:01:27,560 --> 00:01:29,719 You know, whether it comes to simple things 41 00:01:29,719 --> 00:01:32,600 like hiring and firing staff or figuring out 42 00:01:32,600 --> 00:01:35,420 how to allocate funds or even funding research, 43 00:01:35,799 --> 00:01:38,299 when you're in private practice, there's less, 44 00:01:39,880 --> 00:01:41,900 administrative challenges and oversight, 45 00:01:42,465 --> 00:01:43,685 and it allows 46 00:01:44,064 --> 00:01:45,525 people, especially entrepreneurial 47 00:01:45,905 --> 00:01:46,724 people or, 48 00:01:47,504 --> 00:01:49,104 people with other interest to be able to 49 00:01:49,104 --> 00:01:51,604 continue working forward in your private practice 50 00:01:51,984 --> 00:01:53,424 and build it in the way that you 51 00:01:53,424 --> 00:01:55,700 see fit. So, you know, we we all 52 00:01:55,700 --> 00:01:57,540 have people that are our bosses, whether it 53 00:01:57,540 --> 00:01:59,319 be my chair or the president of the 54 00:01:59,319 --> 00:02:00,200 of the organization. 55 00:02:01,060 --> 00:02:03,140 But when you're in private practice, there tends 56 00:02:03,140 --> 00:02:06,020 to be more ability to to, I'll say, 57 00:02:06,020 --> 00:02:08,040 form the practice you wanna have, 58 00:02:09,075 --> 00:02:10,435 whether it being in the days of the 59 00:02:10,435 --> 00:02:12,915 week that you're seeing or operating, your travel 60 00:02:12,915 --> 00:02:13,415 schedule, 61 00:02:13,715 --> 00:02:15,715 your vacation schedule. It's just a lot of 62 00:02:15,715 --> 00:02:16,215 freedom. 63 00:02:16,995 --> 00:02:19,155 And that pairs nicely with the advantages of 64 00:02:19,155 --> 00:02:21,155 academics, which are to work with residents and 65 00:02:21,155 --> 00:02:23,610 fellows is really, I would say, the most 66 00:02:23,610 --> 00:02:25,370 rewarding thing that I do. Teaching is a 67 00:02:25,370 --> 00:02:27,530 lot of fun. It's invigorating to work with 68 00:02:27,530 --> 00:02:28,349 young people. 69 00:02:29,610 --> 00:02:32,090 Doing research is just a blast. It's you 70 00:02:32,090 --> 00:02:33,849 feel like you're really for you know, helping 71 00:02:33,849 --> 00:02:35,789 the field move forward. And so, 72 00:02:36,384 --> 00:02:38,485 to basically be able to pair those advantages 73 00:02:38,544 --> 00:02:40,865 together of private practice and academics is is 74 00:02:40,865 --> 00:02:41,844 really a gift. 75 00:02:42,625 --> 00:02:44,324 I mean, thinking about the, you know, the 76 00:02:44,544 --> 00:02:45,604 the young residents, 77 00:02:45,905 --> 00:02:49,205 fellows, the med students, future of spine surgery. 78 00:02:49,905 --> 00:02:50,564 Are you 79 00:02:51,219 --> 00:02:51,719 optimistic, 80 00:02:52,180 --> 00:02:52,680 nervous? 81 00:02:53,140 --> 00:02:54,760 What are some of the big, 82 00:02:55,700 --> 00:02:57,879 lessons that you're preparing them for? 83 00:02:58,659 --> 00:03:01,060 Well, I'm an eternal optimist. I'm I'm completely 84 00:03:01,060 --> 00:03:02,360 optimistic. I think 85 00:03:02,659 --> 00:03:05,480 despite the challenges of modern health care, 86 00:03:06,085 --> 00:03:08,104 there are patients who will need their spines 87 00:03:08,485 --> 00:03:10,585 and orthopedic problems taken care of, 88 00:03:11,365 --> 00:03:11,865 forever. 89 00:03:12,245 --> 00:03:14,805 And so the world needs us. And despite 90 00:03:14,805 --> 00:03:17,044 some recent news that, oh, maybe robots will 91 00:03:17,044 --> 00:03:19,444 be replacing surgeons, that's just is not the 92 00:03:19,444 --> 00:03:19,944 case. 93 00:03:21,040 --> 00:03:23,040 We will be needed by society to help 94 00:03:23,040 --> 00:03:24,260 take care of people. 95 00:03:24,719 --> 00:03:26,800 And to do so is a true honor, 96 00:03:26,800 --> 00:03:28,800 and it's fun, and it's exciting, and the 97 00:03:28,800 --> 00:03:30,340 field continues to move quickly. 98 00:03:30,800 --> 00:03:33,280 And so I'm completely optimistic about spine. I 99 00:03:33,280 --> 00:03:33,780 think 100 00:03:34,495 --> 00:03:36,575 there are many challenges that we'll all face 101 00:03:36,575 --> 00:03:38,754 that I'm sure we'll talk about today, but 102 00:03:38,814 --> 00:03:40,415 our job is just to figure out how 103 00:03:40,415 --> 00:03:42,575 to navigate them, to figure out how to 104 00:03:42,575 --> 00:03:44,735 advocate for, you know, our specialty and for 105 00:03:44,735 --> 00:03:47,079 medicine and for our patients in general, and 106 00:03:47,079 --> 00:03:48,439 to just figure out how to take the 107 00:03:48,439 --> 00:03:50,120 best care of patients we can in the 108 00:03:50,120 --> 00:03:51,579 system that we were dealt. 109 00:03:52,199 --> 00:03:54,199 I like that. You're a very glass half 110 00:03:54,199 --> 00:03:55,900 full type of guy. Yes. 111 00:03:56,759 --> 00:03:58,359 And so then, you know, you did mention 112 00:03:58,359 --> 00:04:01,500 headwinds, you know, especially from the private practice 113 00:04:01,719 --> 00:04:02,219 perspective. 114 00:04:02,784 --> 00:04:05,205 What are some of the biggest headwinds you're 115 00:04:05,745 --> 00:04:07,664 anticipating, and how are you gonna get ahead 116 00:04:07,664 --> 00:04:08,324 of them? 117 00:04:09,104 --> 00:04:12,324 I think the primary headwind that we all 118 00:04:12,784 --> 00:04:14,164 have to face 119 00:04:14,465 --> 00:04:16,545 is really reimbursement. And and it's a little 120 00:04:16,545 --> 00:04:17,605 disappointing because 121 00:04:18,639 --> 00:04:21,199 inflation is obviously a problem in society as 122 00:04:21,199 --> 00:04:24,019 a whole, but to see Medicare reimbursement dropping 123 00:04:25,279 --> 00:04:27,599 paired with the fact that private payers tend 124 00:04:27,599 --> 00:04:29,620 to tie their reimbursement rates to Medicare, 125 00:04:30,319 --> 00:04:33,704 it's it is concerning. Now, again, I'm glass 126 00:04:33,704 --> 00:04:35,404 half full. We're gonna find ways 127 00:04:36,104 --> 00:04:38,024 to continue to deliver care. We're gonna find 128 00:04:38,024 --> 00:04:40,504 ways to be financially viable, but we have 129 00:04:40,504 --> 00:04:42,104 to run a business. That's the thing about 130 00:04:42,104 --> 00:04:43,564 private practice is that 131 00:04:44,024 --> 00:04:44,925 I have employees 132 00:04:45,305 --> 00:04:47,464 who I give a raise to every year, 133 00:04:47,464 --> 00:04:48,204 of course, 134 00:04:48,699 --> 00:04:50,220 because they deserve it and they need it 135 00:04:50,220 --> 00:04:52,319 and they they work very hard. 136 00:04:52,939 --> 00:04:55,899 But if, you know, reimbursement keeps getting cut 137 00:04:55,899 --> 00:04:57,120 by the insurance companies, 138 00:04:58,379 --> 00:05:00,720 at some point, that is a problem because 139 00:05:01,254 --> 00:05:03,915 the money's gotta come from somewhere. And so, 140 00:05:04,134 --> 00:05:06,855 clearly, you know, we can financially revenue streams 141 00:05:06,855 --> 00:05:08,855 and other ways to continue making sure to 142 00:05:08,855 --> 00:05:10,555 have a viable business, but 143 00:05:10,855 --> 00:05:12,154 that headwind itself 144 00:05:12,694 --> 00:05:14,870 is the one that's at the forefront of 145 00:05:14,870 --> 00:05:16,310 many of our minds, and we really just 146 00:05:16,310 --> 00:05:17,750 have to keep a very close eye on 147 00:05:17,750 --> 00:05:18,250 it, 148 00:05:18,629 --> 00:05:20,870 carefully monitor it, and have, you know, short 149 00:05:20,870 --> 00:05:22,470 term and long term plans to deal with 150 00:05:22,470 --> 00:05:24,410 it. But the problem is 151 00:05:24,790 --> 00:05:26,149 since so much of it is out of 152 00:05:26,149 --> 00:05:28,884 our control, you know, if the federal government 153 00:05:29,665 --> 00:05:30,965 were to cut reimbursement 154 00:05:31,345 --> 00:05:31,845 drastically, 155 00:05:32,145 --> 00:05:35,185 that's just a budget problem that happens immediately 156 00:05:35,185 --> 00:05:36,324 that has to be resolved. 157 00:05:37,345 --> 00:05:38,944 Got it. And, you know, how are you 158 00:05:38,944 --> 00:05:39,764 thinking about 159 00:05:40,145 --> 00:05:42,545 them growing over the next twelve to twenty 160 00:05:42,545 --> 00:05:43,285 four months? 161 00:05:44,680 --> 00:05:46,060 Growth is always challenging, 162 00:05:47,399 --> 00:05:49,800 for me, for example, because I'm a very 163 00:05:49,800 --> 00:05:51,560 busy spine surgeon who's been busy for a 164 00:05:51,560 --> 00:05:52,539 number of years. 165 00:05:52,839 --> 00:05:55,819 Mhmm. So I can't just think about growing 166 00:05:56,039 --> 00:05:58,519 by doing more cases because that really can't 167 00:05:58,519 --> 00:06:01,365 be done. And I one interesting thing about 168 00:06:01,365 --> 00:06:03,444 a busy spine practice is you also can't 169 00:06:03,444 --> 00:06:05,544 just grow by seeing more patients because 170 00:06:06,564 --> 00:06:08,404 you have to be very careful, especially if 171 00:06:08,404 --> 00:06:10,245 you have a mature spine practice. If you 172 00:06:10,245 --> 00:06:12,084 see more patients, there will be more surgeries 173 00:06:12,084 --> 00:06:12,985 that come through, 174 00:06:13,339 --> 00:06:15,020 and you won't have time to do them, 175 00:06:15,020 --> 00:06:16,560 at least not in a timely manner. 176 00:06:17,180 --> 00:06:18,779 At least in this country, we tend to 177 00:06:18,779 --> 00:06:21,180 try to give people surgery within a reasonable 178 00:06:21,180 --> 00:06:22,779 amount of time. Spine patients are in a 179 00:06:22,779 --> 00:06:24,540 lot of pain. If you tell them they 180 00:06:24,540 --> 00:06:26,584 have to wait three months or six months 181 00:06:26,584 --> 00:06:27,324 for surgery, 182 00:06:27,785 --> 00:06:30,204 that I mean, it's it's just not compassionate 183 00:06:30,264 --> 00:06:31,625 to the patient, number one, and it may 184 00:06:31,625 --> 00:06:33,725 not be tenable to a practice. And so 185 00:06:34,185 --> 00:06:34,764 I think 186 00:06:35,544 --> 00:06:37,305 at least in terms of our practice, we've 187 00:06:37,305 --> 00:06:39,084 thought about growth in a number of ways. 188 00:06:39,310 --> 00:06:40,990 Number one is that we have grown by 189 00:06:40,990 --> 00:06:43,870 hiring multiple young spine surgeons and then putting 190 00:06:43,870 --> 00:06:44,769 them out into, 191 00:06:45,229 --> 00:06:47,169 nearby communities that have need. 192 00:06:47,709 --> 00:06:50,350 There's data that's been published multiple times that 193 00:06:50,350 --> 00:06:51,970 says the volume of spine surgery 194 00:06:52,375 --> 00:06:54,535 is directly correlated to the number of spine 195 00:06:54,535 --> 00:06:56,375 surgeons rather than the number of patients who 196 00:06:56,375 --> 00:06:58,694 need spine surgery. And so we've been careful 197 00:06:58,694 --> 00:07:00,454 to try not to just hire spine surgeons 198 00:07:00,454 --> 00:07:02,774 and put them in relatively saturated areas, but 199 00:07:02,774 --> 00:07:03,514 to find 200 00:07:03,894 --> 00:07:04,394 hospitals, 201 00:07:04,694 --> 00:07:06,394 hospital systems, and regions 202 00:07:07,415 --> 00:07:07,915 that 203 00:07:08,269 --> 00:07:09,949 really have deficient spine care. You know, the 204 00:07:09,949 --> 00:07:12,189 patients are currently having to travel long distances 205 00:07:12,189 --> 00:07:13,709 and to try to give them service right 206 00:07:13,709 --> 00:07:16,269 in their backyard. So for us, the growth 207 00:07:16,269 --> 00:07:18,350 first is by hiring spine surgeons. Second is 208 00:07:18,350 --> 00:07:19,730 by continuing to offer 209 00:07:20,189 --> 00:07:22,129 ancillary services to them, 210 00:07:22,475 --> 00:07:25,035 such as additional, you know, physical therapy services 211 00:07:25,035 --> 00:07:27,675 or other pain management services to help help 212 00:07:27,675 --> 00:07:30,735 them alleviate their pain through nonsurgical methods. 213 00:07:31,435 --> 00:07:32,095 And then 214 00:07:32,794 --> 00:07:35,035 lastly is through complexity of care. We we 215 00:07:35,035 --> 00:07:37,375 have really prided ourselves at Brown on being 216 00:07:37,729 --> 00:07:39,509 a true tertiary or quaternary 217 00:07:40,129 --> 00:07:41,970 center for spine. We take care of any 218 00:07:41,970 --> 00:07:44,050 spine problem that exists as complex as it 219 00:07:44,050 --> 00:07:46,209 can be because a lot of these community 220 00:07:46,209 --> 00:07:48,689 centers can't do that. And so to be 221 00:07:48,689 --> 00:07:50,129 able to take care of the most of 222 00:07:50,129 --> 00:07:51,589 the most complex problems 223 00:07:52,115 --> 00:07:53,795 is at least a a way that I 224 00:07:53,795 --> 00:07:54,295 see, 225 00:07:55,235 --> 00:07:57,154 it's a different type of growth, but it 226 00:07:57,154 --> 00:07:58,455 is still growth nonetheless. 227 00:07:59,074 --> 00:08:00,455 Yeah. It sounds like an absolute, 228 00:08:00,995 --> 00:08:03,154 win win approach when you're bringing in these 229 00:08:03,154 --> 00:08:05,955 new surgeons and then putting them in these, 230 00:08:06,900 --> 00:08:08,120 underserved areas. 231 00:08:08,900 --> 00:08:11,139 That's right. Yeah. And then, you know, I 232 00:08:11,139 --> 00:08:12,980 wanted to pick your brain on just yeah. 233 00:08:12,980 --> 00:08:15,639 I know you're an expert in spinal deformity 234 00:08:15,779 --> 00:08:17,960 care, and I was wondering what innovations 235 00:08:18,819 --> 00:08:20,920 you're most excited about in that area. 236 00:08:21,875 --> 00:08:23,475 Yeah. It is really exciting. And it let 237 00:08:23,475 --> 00:08:25,555 me tell you, it's very humbling because treating 238 00:08:25,555 --> 00:08:26,455 spinal deformity, 239 00:08:26,915 --> 00:08:29,314 when it goes well, it's incredibly life changing 240 00:08:29,314 --> 00:08:30,055 for the patients. 241 00:08:30,514 --> 00:08:33,475 It's amazingly smooth, actually. These surgeries are invasive, 242 00:08:33,475 --> 00:08:35,940 but people can bounce back really quick. Mhmm. 243 00:08:36,340 --> 00:08:38,580 But when it doesn't go smoothly, they can 244 00:08:38,580 --> 00:08:40,360 be so disastrous with, 245 00:08:40,980 --> 00:08:44,580 you know, repeat and multiple surgeries, complex medical 246 00:08:44,580 --> 00:08:45,080 complications, 247 00:08:45,460 --> 00:08:48,279 revision surgery after revision surgery. And so 248 00:08:49,074 --> 00:08:51,334 what what I see most exciting about 249 00:08:51,875 --> 00:08:54,054 spinal deformity, I would say three different things. 250 00:08:54,514 --> 00:08:57,654 The first would be using data and AI 251 00:08:58,115 --> 00:09:00,054 to select patients, 252 00:09:01,074 --> 00:09:02,934 that are optimal for surgery, 253 00:09:03,429 --> 00:09:04,809 figuring out what their optimization 254 00:09:05,110 --> 00:09:07,529 plans are, and then providing the most optimal 255 00:09:07,590 --> 00:09:08,090 treatment. 256 00:09:08,790 --> 00:09:10,250 It's hard to do because 257 00:09:10,629 --> 00:09:12,470 there's such variability in the way we treat 258 00:09:12,470 --> 00:09:14,710 spine patients. There's one surgeon who might do 259 00:09:14,710 --> 00:09:17,225 anterior approaches or another one that does lateral 260 00:09:17,225 --> 00:09:19,065 approaches. Someone else says I do well posterior 261 00:09:19,065 --> 00:09:20,125 approaches, and someone 262 00:09:20,585 --> 00:09:22,264 surgeon might say I'll do a short fusion 263 00:09:22,264 --> 00:09:24,024 for this patient while another surgeon would do 264 00:09:24,024 --> 00:09:26,105 a long fusion. And anytime you see that 265 00:09:26,105 --> 00:09:26,845 much variability, 266 00:09:27,945 --> 00:09:29,465 you have a problem on your hands. It 267 00:09:29,465 --> 00:09:31,080 means you probably don't have 268 00:09:31,480 --> 00:09:33,179 optimized data or delivery. 269 00:09:33,559 --> 00:09:36,940 And so I think over time through improved, 270 00:09:37,960 --> 00:09:40,360 data initiatives and AI, we're going to be 271 00:09:40,360 --> 00:09:42,540 delivering better evidence based care. 272 00:09:43,080 --> 00:09:45,980 Mhmm. The next thing is specialized teams. 273 00:09:46,875 --> 00:09:47,774 It is absolutely 274 00:09:48,394 --> 00:09:50,475 mandatory that you have a team that's adept 275 00:09:50,475 --> 00:09:53,115 to treating spinal deformity because I've seen people 276 00:09:53,115 --> 00:09:54,875 out in the community do these fairly complex 277 00:09:54,875 --> 00:09:57,355 cases. The surgeon's very skilled, and the patient 278 00:09:57,355 --> 00:09:59,835 starts having a problem and some some staff 279 00:09:59,835 --> 00:10:02,220 member or someone else doesn't really know what 280 00:10:02,220 --> 00:10:04,240 to look out for and then a catastrophic 281 00:10:04,379 --> 00:10:05,440 complication ensues. 282 00:10:05,820 --> 00:10:07,519 So if you're gonna do this kinda work, 283 00:10:07,740 --> 00:10:08,720 you need to have, 284 00:10:09,259 --> 00:10:12,220 front desk staff and administrative staff, nursing staff, 285 00:10:12,220 --> 00:10:13,199 physical therapy, 286 00:10:13,500 --> 00:10:16,220 the OR, everybody who's used to treating this 287 00:10:16,220 --> 00:10:17,600 kind of thing. And that's why 288 00:10:17,945 --> 00:10:19,705 what we've done at Brown and the Miriam 289 00:10:19,705 --> 00:10:20,284 is built 290 00:10:20,745 --> 00:10:23,464 a very highly skilled team of people who 291 00:10:23,464 --> 00:10:25,245 actually have an interest in this problem. 292 00:10:25,784 --> 00:10:27,384 You can't just have people who say like, 293 00:10:27,384 --> 00:10:29,625 oh, yeah. Yeah. I I do orthopedics. It's 294 00:10:29,705 --> 00:10:31,644 that's not enough. It has to be people 295 00:10:32,330 --> 00:10:35,210 who know complex spine and spinal deformity. And 296 00:10:35,210 --> 00:10:36,509 then the the last thing 297 00:10:36,970 --> 00:10:39,049 is alignment. We've done a lot of work 298 00:10:39,049 --> 00:10:40,190 in spinal alignment. 299 00:10:40,570 --> 00:10:42,889 We're making some great progress in terms of 300 00:10:42,889 --> 00:10:44,990 figuring out optimal alignment for patients. 301 00:10:45,450 --> 00:10:46,830 And there's some very exciting 302 00:10:47,294 --> 00:10:48,674 products coming out in the pipeline, 303 00:10:49,615 --> 00:10:51,235 that will be, you 304 00:10:51,615 --> 00:10:52,355 know, specific 305 00:10:52,815 --> 00:10:55,534 patient implants for their alignment that I think 306 00:10:55,534 --> 00:10:57,235 will really continue to revolutionize 307 00:10:57,615 --> 00:10:59,714 complex spine and spine fusion care. 308 00:11:00,830 --> 00:11:03,230 So, like, lots of moving parts, it sounds 309 00:11:03,230 --> 00:11:03,730 like. 310 00:11:04,509 --> 00:11:05,330 Yep. Definitely. 311 00:11:05,790 --> 00:11:07,470 Yeah. And then just some last question for 312 00:11:07,470 --> 00:11:10,370 you, doctor Daniels. Can you just go through 313 00:11:10,750 --> 00:11:13,950 three big trends that you're following closest in 314 00:11:13,950 --> 00:11:14,930 health care today? 315 00:11:16,184 --> 00:11:17,565 Absolutely. I think 316 00:11:18,105 --> 00:11:19,804 I think the first trend, 317 00:11:20,985 --> 00:11:22,904 has to do with reimbursement as we talked 318 00:11:22,904 --> 00:11:26,585 about, but is also closely tied to value 319 00:11:26,585 --> 00:11:28,825 based and outcome driven care. I think they're 320 00:11:28,825 --> 00:11:30,044 all wrapped in together. 321 00:11:30,450 --> 00:11:32,610 Now we've been talking about value based and 322 00:11:32,610 --> 00:11:34,629 outcome driven care for a long time. 323 00:11:35,009 --> 00:11:37,169 And it's not like it's just all gonna 324 00:11:37,169 --> 00:11:38,370 be a wave and show up in the 325 00:11:38,370 --> 00:11:39,889 next six months or one year or two 326 00:11:39,889 --> 00:11:41,669 years, but it is coming, 327 00:11:42,290 --> 00:11:44,610 especially in spine because poor outcomes are not 328 00:11:44,610 --> 00:11:45,110 sustainable. 329 00:11:46,004 --> 00:11:48,264 And somehow, we as a field 330 00:11:48,884 --> 00:11:50,024 need to figure out 331 00:11:50,644 --> 00:11:51,144 how 332 00:11:51,605 --> 00:11:52,105 to 333 00:11:52,485 --> 00:11:55,225 help the insurance companies and help the payers 334 00:11:56,004 --> 00:11:58,565 with outcome driven care and value based care. 335 00:11:58,565 --> 00:12:00,665 And it's really hard because 336 00:12:01,899 --> 00:12:03,279 measuring outcomes is difficult. 337 00:12:03,740 --> 00:12:05,659 Centers like ours that take care of really 338 00:12:05,659 --> 00:12:07,820 complex spine problems, you know, we'll take patients 339 00:12:07,820 --> 00:12:09,339 from all over the region that have already 340 00:12:09,339 --> 00:12:11,259 had failed spine surgery. And the reality is 341 00:12:11,259 --> 00:12:13,899 though patients don't always do well. And so 342 00:12:13,899 --> 00:12:15,980 if we are purely in an outcome driven 343 00:12:15,980 --> 00:12:17,975 care model and we take those really tough 344 00:12:17,975 --> 00:12:18,875 cases on, 345 00:12:19,975 --> 00:12:21,995 there may be payers who don't wanna reimburse 346 00:12:22,054 --> 00:12:24,375 us well for that, because our outcomes are 347 00:12:24,375 --> 00:12:26,375 poor. And so I think it's going to 348 00:12:26,375 --> 00:12:28,235 take some collaborative effort between 349 00:12:28,695 --> 00:12:30,315 spine specialists, practice, 350 00:12:30,690 --> 00:12:33,090 hospital systems, and the insurers to figure out 351 00:12:33,090 --> 00:12:35,669 what that really means for outcome based care. 352 00:12:36,529 --> 00:12:37,830 The second would be 353 00:12:38,610 --> 00:12:40,850 also something we briefly touched on, which is 354 00:12:40,850 --> 00:12:44,230 data integration and AI enabled decision support. 355 00:12:44,850 --> 00:12:46,230 Basically meaning that 356 00:12:46,584 --> 00:12:48,845 we just must use data better 357 00:12:49,225 --> 00:12:52,424 to help deliver more evidence based care. Because 358 00:12:52,424 --> 00:12:54,745 if we don't do it, that variability is 359 00:12:54,745 --> 00:12:57,065 what's gonna kill us because it makes us 360 00:12:57,065 --> 00:12:58,764 look like we don't know what we're doing. 361 00:12:58,904 --> 00:13:01,259 And the people with poor outcomes can keep 362 00:13:01,500 --> 00:13:04,460 basically delivering that poor care at very high 363 00:13:04,460 --> 00:13:05,360 cost levels. 364 00:13:05,740 --> 00:13:07,500 And eventually, as we know, the payers are 365 00:13:07,500 --> 00:13:09,899 gonna look and say, we're paying way too 366 00:13:09,899 --> 00:13:11,820 much for spinal fusion and the patients are 367 00:13:11,820 --> 00:13:13,980 doing poorly. When in reality, if you look 368 00:13:13,980 --> 00:13:14,720 at the subset 369 00:13:15,340 --> 00:13:16,480 who are doing great, 370 00:13:16,944 --> 00:13:17,444 it's 371 00:13:17,745 --> 00:13:20,245 excellent care that's delivered at a very reasonable 372 00:13:20,304 --> 00:13:22,304 value. But I think we're going to need 373 00:13:22,304 --> 00:13:23,444 AI to do that. 374 00:13:24,304 --> 00:13:26,784 I think the the last thing is probably 375 00:13:26,784 --> 00:13:29,745 just the sustainability of the workforce, and and 376 00:13:29,745 --> 00:13:31,924 that's not just the spine surgeons and, 377 00:13:32,889 --> 00:13:35,950 coming from both neurosurgery and orthopedics. It's really 378 00:13:37,049 --> 00:13:38,750 figuring out how to keep, 379 00:13:39,929 --> 00:13:40,990 nursing staff, 380 00:13:41,290 --> 00:13:43,790 administrative staff, all the support staff, 381 00:13:44,674 --> 00:13:45,654 basically engaged. 382 00:13:46,195 --> 00:13:47,815 And it's a challenge because 383 00:13:48,274 --> 00:13:49,735 as we know, the 384 00:13:50,674 --> 00:13:53,154 expense of keeping really high quality staff is 385 00:13:53,154 --> 00:13:54,695 high. We've seen multiple 386 00:13:55,154 --> 00:13:57,860 union strikes from nurses here in our region 387 00:13:58,000 --> 00:14:00,480 and reasonably so. I understand it. It's because 388 00:14:00,480 --> 00:14:02,179 they have to vouch for their own 389 00:14:02,559 --> 00:14:03,059 livelihoods. 390 00:14:03,519 --> 00:14:05,679 But I think figuring out how to have 391 00:14:05,679 --> 00:14:07,139 true team based models 392 00:14:07,519 --> 00:14:09,440 will be really important. And we've had to 393 00:14:09,440 --> 00:14:11,779 fight that battle and we're continuing to regionally 394 00:14:11,919 --> 00:14:12,419 because 395 00:14:12,985 --> 00:14:14,445 everyone has a slightly different, 396 00:14:16,024 --> 00:14:18,665 viewpoint of what's important, meaning that the hospital 397 00:14:18,665 --> 00:14:20,184 just has to make sure there's nurses on 398 00:14:20,184 --> 00:14:21,865 every floor that can take care of every 399 00:14:21,865 --> 00:14:24,184 problem when I'm laser focused on making sure 400 00:14:24,184 --> 00:14:26,345 my spinal deformity patient has a nurse that's 401 00:14:26,345 --> 00:14:27,965 highly specialized in 402 00:14:28,589 --> 00:14:29,329 spinal deformity. 403 00:14:30,029 --> 00:14:32,110 And it works in relatively big hospitals, but 404 00:14:32,110 --> 00:14:33,949 as hospitals get smaller and smaller, of course, 405 00:14:33,949 --> 00:14:36,289 it's harder because you can't have ultra subspecialized 406 00:14:36,509 --> 00:14:39,549 teams and small subspecialty or excuse me, small 407 00:14:39,549 --> 00:14:42,269 community hospitals. So I think that's a challenge 408 00:14:42,269 --> 00:14:45,024 that we are gonna continue fighting and we'll 409 00:14:45,024 --> 00:14:46,644 look at different in different communities. 410 00:14:47,664 --> 00:14:50,065 Got it. Well, doctor Daniels, thank you so 411 00:14:50,065 --> 00:14:52,225 much for joining us today. It's a pleasure 412 00:14:52,225 --> 00:14:53,825 speaking with you, and I hope to connect 413 00:14:53,825 --> 00:14:54,965 again down the line. 414 00:14:55,470 --> 00:14:57,710 I really appreciate it, and thank you so 415 00:14:57,710 --> 00:14:59,390 much. Look forward to talking again at some 416 00:14:59,390 --> 00:14:59,890 point.