This is Carly Beam with Becker Spine and
Orthopedics podcast. I'm thrilled to be joined today
by doctor Alan Daniels. Doctor Daniels, thank you
for joining us. Thanks for having me. So
before we dive into our questions, I wanted
you to just please introduce yourself and share
a bit more about your background.
Yeah. So I'm an orthopedic spine surgeon in
Providence, Rhode Island at Brown University.
I did my training here and and stayed
on. And one of the main reasons was
we have an organization called University Orthopedics, which
is a private practice. It's a large orthopedic
practice with 70 surgeons
that basically is a
center that owns,
around real estate.
We have ancillary services, and we have facilities
all over the region. And it's just has
been a very rewarding way to practice and
that I get to,
have a very
fruitful,
I'll say, private practice while I also
do a lot of academics,
teach residents, fellows, and work very closely with
the university. So it's really a perfect mix
for me.
Definitely. And I'd love to hear, you know,
what are the biggest advantages you've
been seeing both working from a private practice
perspective
and then also in the academic setting?
Well, you really nailed it on the head
in that there are advantages to each, and
that's why it's so nice being in a
in a private academic environment.
Mhmm. The advantages of private practice are that
we have a lot of autonomy.
You know, whether it comes to simple things
like hiring and firing staff or figuring out
how to allocate funds or even funding research,
when you're in private practice, there's less,
administrative challenges and oversight,
and it allows
people, especially entrepreneurial
people or,
people with other interest to be able to
continue working forward in your private practice
and build it in the way that you
see fit. So, you know, we we all
have people that are our bosses, whether it
be my chair or the president of the
of the organization.
But when you're in private practice, there tends
to be more ability to to, I'll say,
form the practice you wanna have,
whether it being in the days of the
week that you're seeing or operating, your travel
schedule,
your vacation schedule. It's just a lot of
freedom.
And that pairs nicely with the advantages of
academics, which are to work with residents and
fellows is really, I would say, the most
rewarding thing that I do. Teaching is a
lot of fun. It's invigorating to work with
young people.
Doing research is just a blast. It's you
feel like you're really for you know, helping
the field move forward. And so,
to basically be able to pair those advantages
together of private practice and academics is is
really a gift.
I mean, thinking about the, you know, the
the young residents,
fellows, the med students, future of spine surgery.
Are you
optimistic,
nervous?
What are some of the big,
lessons that you're preparing them for?
Well, I'm an eternal optimist. I'm I'm completely
optimistic. I think
despite the challenges of modern health care,
there are patients who will need their spines
and orthopedic problems taken care of,
forever.
And so the world needs us. And despite
some recent news that, oh, maybe robots will
be replacing surgeons, that's just is not the
case.
We will be needed by society to help
take care of people.
And to do so is a true honor,
and it's fun, and it's exciting, and the
field continues to move quickly.
And so I'm completely optimistic about spine. I
think
there are many challenges that we'll all face
that I'm sure we'll talk about today, but
our job is just to figure out how
to navigate them, to figure out how to
advocate for, you know, our specialty and for
medicine and for our patients in general, and
to just figure out how to take the
best care of patients we can in the
system that we were dealt.
I like that. You're a very glass half
full type of guy. Yes.
And so then, you know, you did mention
headwinds, you know, especially from the private practice
perspective.
What are some of the biggest headwinds you're
anticipating, and how are you gonna get ahead
of them?
I think the primary headwind that we all
have to face
is really reimbursement. And and it's a little
disappointing because
inflation is obviously a problem in society as
a whole, but to see Medicare reimbursement dropping
paired with the fact that private payers tend
to tie their reimbursement rates to Medicare,
it's it is concerning. Now, again, I'm glass
half full. We're gonna find ways
to continue to deliver care. We're gonna find
ways to be financially viable, but we have
to run a business. That's the thing about
private practice is that
I have employees
who I give a raise to every year,
of course,
because they deserve it and they need it
and they they work very hard.
But if, you know, reimbursement keeps getting cut
by the insurance companies,
at some point, that is a problem because
the money's gotta come from somewhere. And so,
clearly, you know, we can financially revenue streams
and other ways to continue making sure to
have a viable business, but
that headwind itself
is the one that's at the forefront of
many of our minds, and we really just
have to keep a very close eye on
it,
carefully monitor it, and have, you know, short
term and long term plans to deal with
it. But the problem is
since so much of it is out of
our control, you know, if the federal government
were to cut reimbursement
drastically,
that's just a budget problem that happens immediately
that has to be resolved.
Got it. And, you know, how are you
thinking about
them growing over the next twelve to twenty
four months?
Growth is always challenging,
for me, for example, because I'm a very
busy spine surgeon who's been busy for a
number of years.
Mhmm. So I can't just think about growing
by doing more cases because that really can't
be done. And I one interesting thing about
a busy spine practice is you also can't
just grow by seeing more patients because
you have to be very careful, especially if
you have a mature spine practice. If you
see more patients, there will be more surgeries
that come through,
and you won't have time to do them,
at least not in a timely manner.
At least in this country, we tend to
try to give people surgery within a reasonable
amount of time. Spine patients are in a
lot of pain. If you tell them they
have to wait three months or six months
for surgery,
that I mean, it's it's just not compassionate
to the patient, number one, and it may
not be tenable to a practice. And so
I think
at least in terms of our practice, we've
thought about growth in a number of ways.
Number one is that we have grown by
hiring multiple young spine surgeons and then putting
them out into,
nearby communities that have need.
There's data that's been published multiple times that
says the volume of spine surgery
is directly correlated to the number of spine
surgeons rather than the number of patients who
need spine surgery. And so we've been careful
to try not to just hire spine surgeons
and put them in relatively saturated areas, but
to find
hospitals,
hospital systems, and regions
that
really have deficient spine care. You know, the
patients are currently having to travel long distances
and to try to give them service right
in their backyard. So for us, the growth
first is by hiring spine surgeons. Second is
by continuing to offer
ancillary services to them,
such as additional, you know, physical therapy services
or other pain management services to help help
them alleviate their pain through nonsurgical methods.
And then
lastly is through complexity of care. We we
have really prided ourselves at Brown on being
a true tertiary or quaternary
center for spine. We take care of any
spine problem that exists as complex as it
can be because a lot of these community
centers can't do that. And so to be
able to take care of the most of
the most complex problems
is at least a a way that I
see,
it's a different type of growth, but it
is still growth nonetheless.
Yeah. It sounds like an absolute,
win win approach when you're bringing in these
new surgeons and then putting them in these,
underserved areas.
That's right. Yeah. And then, you know, I
wanted to pick your brain on just yeah.
I know you're an expert in spinal deformity
care, and I was wondering what innovations
you're most excited about in that area.
Yeah. It is really exciting. And it let
me tell you, it's very humbling because treating
spinal deformity,
when it goes well, it's incredibly life changing
for the patients.
It's amazingly smooth, actually. These surgeries are invasive,
but people can bounce back really quick. Mhmm.
But when it doesn't go smoothly, they can
be so disastrous with,
you know, repeat and multiple surgeries, complex medical
complications,
revision surgery after revision surgery. And so
what what I see most exciting about
spinal deformity, I would say three different things.
The first would be using data and AI
to select patients,
that are optimal for surgery,
figuring out what their optimization
plans are, and then providing the most optimal
treatment.
It's hard to do because
there's such variability in the way we treat
spine patients. There's one surgeon who might do
anterior approaches or another one that does lateral
approaches. Someone else says I do well posterior
approaches, and someone
surgeon might say I'll do a short fusion
for this patient while another surgeon would do
a long fusion. And anytime you see that
much variability,
you have a problem on your hands. It
means you probably don't have
optimized data or delivery.
And so I think over time through improved,
data initiatives and AI, we're going to be
delivering better evidence based care.
Mhmm. The next thing is specialized teams.
It is absolutely
mandatory that you have a team that's adept
to treating spinal deformity because I've seen people
out in the community do these fairly complex
cases. The surgeon's very skilled, and the patient
starts having a problem and some some staff
member or someone else doesn't really know what
to look out for and then a catastrophic
complication ensues.
So if you're gonna do this kinda work,
you need to have,
front desk staff and administrative staff, nursing staff,
physical therapy,
the OR, everybody who's used to treating this
kind of thing. And that's why
what we've done at Brown and the Miriam
is built
a very highly skilled team of people who
actually have an interest in this problem.
You can't just have people who say like,
oh, yeah. Yeah. I I do orthopedics. It's
that's not enough. It has to be people
who know complex spine and spinal deformity. And
then the the last thing
is alignment. We've done a lot of work
in spinal alignment.
We're making some great progress in terms of
figuring out optimal alignment for patients.
And there's some very exciting
products coming out in the pipeline,
that will be, you
know, specific
patient implants for their alignment that I think
will really continue to revolutionize
complex spine and spine fusion care.
So, like, lots of moving parts, it sounds
like.
Yep. Definitely.
Yeah. And then just some last question for
you, doctor Daniels. Can you just go through
three big trends that you're following closest in
health care today?
Absolutely. I think
I think the first trend,
has to do with reimbursement as we talked
about, but is also closely tied to value
based and outcome driven care. I think they're
all wrapped in together.
Now we've been talking about value based and
outcome driven care for a long time.
And it's not like it's just all gonna
be a wave and show up in the
next six months or one year or two
years, but it is coming,
especially in spine because poor outcomes are not
sustainable.
And somehow, we as a field
need to figure out
how
to
help the insurance companies and help the payers
with outcome driven care and value based care.
And it's really hard because
measuring outcomes is difficult.
Centers like ours that take care of really
complex spine problems, you know, we'll take patients
from all over the region that have already
had failed spine surgery. And the reality is
though patients don't always do well. And so
if we are purely in an outcome driven
care model and we take those really tough
cases on,
there may be payers who don't wanna reimburse
us well for that, because our outcomes are
poor. And so I think it's going to
take some collaborative effort between
spine specialists, practice,
hospital systems, and the insurers to figure out
what that really means for outcome based care.
The second would be
also something we briefly touched on, which is
data integration and AI enabled decision support.
Basically meaning that
we just must use data better
to help deliver more evidence based care. Because
if we don't do it, that variability is
what's gonna kill us because it makes us
look like we don't know what we're doing.
And the people with poor outcomes can keep
basically delivering that poor care at very high
cost levels.
And eventually, as we know, the payers are
gonna look and say, we're paying way too
much for spinal fusion and the patients are
doing poorly. When in reality, if you look
at the subset
who are doing great,
it's
excellent care that's delivered at a very reasonable
value. But I think we're going to need
AI to do that.
I think the the last thing is probably
just the sustainability of the workforce, and and
that's not just the spine surgeons and,
coming from both neurosurgery and orthopedics. It's really
figuring out how to keep,
nursing staff,
administrative staff, all the support staff,
basically engaged.
And it's a challenge because
as we know, the
expense of keeping really high quality staff is
high. We've seen multiple
union strikes from nurses here in our region
and reasonably so. I understand it. It's because
they have to vouch for their own
livelihoods.
But I think figuring out how to have
true team based models
will be really important. And we've had to
fight that battle and we're continuing to regionally
because
everyone has a slightly different,
viewpoint of what's important, meaning that the hospital
just has to make sure there's nurses on
every floor that can take care of every
problem when I'm laser focused on making sure
my spinal deformity patient has a nurse that's
highly specialized in
spinal deformity.
And it works in relatively big hospitals, but
as hospitals get smaller and smaller, of course,
it's harder because you can't have ultra subspecialized
teams and small subspecialty or excuse me, small
community hospitals. So I think that's a challenge
that we are gonna continue fighting and we'll
look at different in different communities.
Got it. Well, doctor Daniels, thank you so
much for joining us today. It's a pleasure
speaking with you, and I hope to connect
again down the line.
I really appreciate it, and thank you so
much. Look forward to talking again at some
point.