Building a spine practice in the 'outcomes economy': Q&A with Dr. Alok Sharan

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Alok Sharan, MD, in October left NJ Spine and Wellness in East Brunswick, N.J., and established his own practice, Spine and Performance Institute, the next month.

Spine and Performance Institute, based in Edison, N.J., aims to reach beyond the operating room and will include services to support a patient's nutrition, and coordinate rehab services and other pre- and postoperative care.

Dr. Sharan spoke with Becker's about how he developed his practice and spine surgery in the "outcomes economy."

Note: This conversation was lightly edited for clarity and length.

Question: How did you decide to open your own practice?

Dr. Alok Sharan: As you know, I am an advocate and pioneer of awake spinal fusion. At this point now if a patient needs a lumbar fusion, we could perform a lumbar fusion as an outpatient procedure, have them discharged within four hours and get them off of pain meds in a few days. It really has become a game changer.

As our awake spinal fusion program evolves, it has become clear to me that as surgeons, we have to take a more holistic approach to optimizing a patient's outcome beyond the operating room. This includes integrating functional medicine and nutritional science, proper prehab and post-op rehab, along with mental health treatment for our surgical patients. If the goal is to achieve the best overall outcomes, then we have to optimize our patient's health beyond the surgery. In healthcare we are living in an "outcomes economy," meaning that payers want to pay for outcomes, and patients are more attuned to achieving the most optimum outcomes.

The name of our practice is the Spine and Performance Institute. I decided to build my own practice to integrate all of these other services (functional medicine, nutritional science, performance science) to achieve the most holistic outcomes for patients who undergo spine surgery. In our office I am partnering up with colleagues who can deliver these services to our patients before and after their spine surgery. Ultimately our goal is to achieve the best overall outcomes for patients who undergo spine surgery, beyond the OR.

Q: To what extent are the gaps in holistic spine care that you're not seeing in traditional settings?

AS: It's an interesting story on who I learned this from. There was a highly functional lady in her 40s who I had performed an awake laminectomy on about a year ago. Overall she achieved a great outcome, at least I thought. We ended up referring her to a functional medicine colleague who was able to further optimize her well-being by looking at various other issues she had, including nutrition and gut health.

She came back to us and said, "I'm really happy [with the surgery], but overall, I feel so much better having gone through that functional medicine program." Let's say she was 80 percent better after our surgery. When she came back, she felt 99 percent better and overall felt that we had a greater impact on her life.

If we are truly going to drive good outcomes, we have to look beyond just delivering a good surgical result and integrate these other services as well. As surgeons we are in a unique position to have the ability to impact and influence our patient's behavior and close down certain gaps in their health. I think specifically there's a big gap with the functional medicine and nutritional movement, and there's a big gap in terms of body mechanics and physical therapy. It's going to be hard for us to address this, but it's something that needs to be addressed.

Q: What are the top challenges you're expecting with implementing holistic care, and how will you address them?

AS: One step at a time. The dominant business model in healthcare (i.e. fee for service) does not support holistic care. We're going to bring in functional medicine and IV nutritionists. We're going to develop a stronger collaboration with our physical therapist and rehab colleagues. And ultimately we will develop a program to treat any mental health issues. Integrating these services while running a business will be challenging.

Q: Do you plan to have all awake spine patients?

AS: Our goal is to build a destination center for patients who need spine surgery and are seeking a holistic approach to their care. I am honored that many patients come from out of state to our practice to undergo awake spine surgery. Ultimately our goal is to try to do the majority of cases awake. Of course, there are going to be some situations where we don't. At the end when a patient qualifies for an awake spine surgery, our goal is to perform them using our protocol.

Q: What's one thing you'd recommend all spine practices implement to improve holistic care?

AS: They have to seek out collaborative partners who share the same vision. So while they may not be able to deliver those resources under their own roof, they can certainly collaborate with colleagues in their area who share the same goals and vision for achieving the highest outcomes over an episode of care.

It's critical because I want to emphasize this notion that we're in this "outcomes economy" now. I know that we've been driving towards better value and better outcomes, and the payers are still trying to figure out the business model on that. But I think even more so, patients are so much more aware of it now post-COVID-19 that they want to have surgery on an outpatient basis. They want to limit opioid use after surgery. And they want an enhanced/faster recovery. Patients themselves are so much more sensitive to achieving an outcome beyond just getting rid of their pain and having a successful surgery.

Q: What advice would you give to other spine surgeons who might want to open their own practice?

AS: Starting your own practice requires a good understanding of business. I am fortunate to have completed a healthcare MBA at Dartmouth, where I learned my foundational business knowledge. There's no formula around creating a successful business. It's going to be a challenge. But I think that most spine surgeons are properly equipped to deal with challenges. It's psychological more than anything else. There are a tremendous amount of resources that are out there to help you start your own practice, so it's not as scary as you think.

The best piece of advice that I can give to a spine surgeon is to think of their brand and what makes them unique. In a competitive marketplace, understanding what is your unique value proposition and how you can effectively deliver it will help you sustain a good practice. 

Q: Is there anything else you'd like to mention?

AS: Our practice is called the Spine and Performance Institute. Having had the good fortune to work with colleagues in the sports medicine field, I have understood the science of performance better. The TB12 brand created by Tom Brady is a good example of this. In sports medicine, when an athlete tears an ACL, there is a lot of good knowledge on how to help them recover quickly and return back to sports.

In spine surgery, we have developed tremendous enhanced recovery protocols. We can learn a lot from our colleagues in other specialties on how to enhance recovery. My goal at the Spine and Performance Institute is to integrate the principles of holistic care, as practiced by functional medicine doctors, along with fast recovery principles that achieves higher performance, as practiced by our sports medicine colleagues, to achieve the best outcomes for patients undergoing spine surgery.

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