Becker's Spine Review

25 THOUGHT LEADERSHIP How big is too big for orthopedic supergroups? 3 surgeons on the consolidation trend By Alan Condon C onsolidation has risen among orthopedic practices during the pandemic, with four super- groups of 100-plus physicians recently formed in Texas, Florida, Tennessee and New Jersey. More independent practices are considering such part- nerships with like-minded groups to provide a launch pad for growth and guard against increasing administra- tive and economic hurdles. Three surgeons reflect on this emerg- ing trend and discuss whether bigger is better when it comes to independent orthopedic practices. Nicholas Grosso, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): There is no limit for how big an independent orthopedic group should be, so long as it is structured in a way that maintains efficiencies amidst growth. With 160 physicians and 60 of- fice locations, my practice, The Centers for Advanced Orthopaedics, is consid- ered a supergroup. When structured appropriately, the benefits of a super- group of our size empowers physicians with the resources needed to navigate the rapidly changing healthcare land- scape while retaining the indepen- dence to practice medicine the way they see fit. Brian Gantwerker, MD. The Craniospi- nal Center of Los Angeles: The size of any private practice group, whether it be two or 200, is immaterial. It is more about the leadership and culture fos- tered. Many times I have seen groups that should work on paper implode and scatter. When I have seen groups work, it is with a fair-minded and logi- cal leader or leaders at the top. They encourage input from everyone, settle disputes openly and discourage back- stabbing behavior. They emanate fairness because they operate on their own example. Inevita- bly, if it's "OK for me, but not for thee," the group is headed for dissolution. It is possible to maintain an "eat-what-you- kill" arrangement if the participating surgeons all see their goal is the same as everyone else's in the room: survival and independence. Strong leaders should be strong not in being the loud- est voice in the room but by their con- sistent confidence, fairness and clarity. Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The answer de- pends on "too big" for what? For bet- ter insurance contracts, the bigger the better. The larger and the more domi- nant a group is in a certain market, the better the rates they can negotiate with private payers. For physician independence, they would probably "top out" at eight to 10 partners. Beyond that, the governance of an organization becomes too com- plex for every partner to participate equally. Executive boards with only a few of the partners get formed. The rest of the physicians start losing some con- trol over how the practice is structured and run. For better quality patient care, it's a lit- tle harder to say. Probably also around 10 partners. The larger the group, the more corporate they become. Most "corporate" groups depend on high patient volume to keep up with ever- increasing overhead and ever-decreas- ing reimbursement. The less time a physician has to spend with a patient, the lower the quality of care typically becomes. n technologies such as robotics and augment- ed reality to improve the precision of surgery, do more minimally invasive surgery to help patients recover faster with fewer complica- tion but also always have option B and C in the back pocket. Tibor Boco, MD. NorthShore Neurological Institute (Arlington Heights, Ill.): One of the most important components of training to become a competent spine surgeon is to develop an appreciation of the anatomy and how it extends in the 3D space beyond direct visualization. is skill is essential to accom- plish adequate decompression and effective instrumentation. Enabling technologies, such as image guidance and robotics, are great adjuncts in our operative armamen- tarium but should not replace a thorough understanding of the anatomy. Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: A discussion I fre- quently have with both my reps and those who train residents is there is a genuine con- cern of the overreliance on tech. Surgeons of a certain vintage who trained on anatomic techniques were slow to adopt them. e next generation seemed more comfortable but were also trained in the backup plan of mapping hardware placement using land- marks and aided by fluoroscopy "just in case." e following generation I hope can still do this. My concern is that instead of verifying and then proceeding, some will just charge ahead, assuming the navigation or technology is spot on. It's more concerning when you think about who exactly is liable when the technol- ogy is "off." I hope the next set of surgeons can see its shortcomings and that the need for anatomical knowledge is paramount. n "e next generation of spine surgeons must be able to do every aspect of spine surgery without the assistance of enabling technology." - Ehsan Jazini, MD. Virginia Spine Institute

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