Alexander Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedic Institute, shared his expertise with Becker's on topics including artificial intelligence and spine robots.
Here are five key quotes:
On leveraging artificial intelligence for billing: We did a lot of things by hand in our billing office. We would send the insurance company a bill and when we eventually got paid we were never really sure if we got paid according to the explanation of benefits. We would then have to go back on each claim and hand adjudicate. The volume of surgeries we do each year is incredible. In Florida alone it is 11,000 cases a year. We automated that with a single-platform electronic revenue cycle management system. Now our claims are accepted, rejected or modified and we receive this information in a much shorter time period. We now can see if the claims were paid as per our contractual agreements. You could just imagine with the volume of surgeries performed at Rothman it is so easy to be underpaid or not paid at all. This risk is now mitigated through technology as a medical care provider only has a limited time period to get reimbursed.
We have exploited AI through tireless bots that check and ensure a surgeon's bills are placed on the date of surgery and are billed according to the accepted pre-authorized schedule. If I used a code that wasn't pre-authorized, AI technology would notify the surgical team appropriately, and the pre-authorization would be updated and submitted to the insurance company. Unless it's a trauma case, you have to obtain pre-authorization for most surgeries with the majority of insurance companies. This technology has assisted in this arduous task.
On increasing ASC physician ownership: Physicians are now more adept at the business skills of running surgical facilities without relying on a management company or hospital system that may demand an inordinate share of distributions. If one decides to use a management company, make sure your goals and vision are similar and the company is focused on minimizing the cost of care and has the clout to negotiate with the primary insurers in the region. Rothman has multiple hospital partners. In our Core Market we have Thomas Jefferson University, Main Line Health, AtlantiCare, Capital Health and down in Florida we have Advent Health.
If you choose to partner with a hospital partner, make sure the system is interested in providing their own physicians that will produce to the same percentage as their ownership percentage. If your hospital partner owns 55% of a facility you want the hospital to assist in having their employed physicians provide approximately 55% of work productivity of the center. In general the work productivity of a multispecialty ASC is often dominated by orthopedic cases. If the share of work is not proportionate to ownership this will eventually lead to dissatisfaction among the physician owners.
On spine robots: Here's the dilemma facing modern surgical training. Everything's based on anatomy. Anatomy determines function. If you don't have a strong understanding of anatomy, you're like a pilot that only knows how to fly a plane using advanced electronics. If the electronics fail then you will be at a loss on how to safely land the plane. That plane may eventually crash. We always have to train our students on the three dimensional anatomy of the spine regardless of the methodology, i.e. text books, articles, cadaver, simulated models etc. Only once anatomy is mastered and basic surgical techniques are learned should we migrate into advanced imaging navigational technologies such as robotics.
I use robotics every week, and it tremendously decreases the mental stress of surgical fixation especially in complex deformity cases while reducing radiation exposure assuming all safeguards are followed. For instance in pelvic fixation you no longer require fluoroscopic guidance and exposure of relevant surgical landmarks to safely place screw anchors. The surgical exposure is much less and screw size can be maximized. But remember, things don't always work out as planned and you need to be able to abandon this technology if necessary and rely on your surgical skills and knowledge to safely complete a case if the technology fails or is not available. It is our responsibility as teachers to train surgeons to understand how to operate using traditional methods such as anatomic landmarks and radiographic imaging.
On spine and orthopedic competition in 2024: Spine and orthopedic surgery are evolving with the advent and incorporation of new technology aimed at improving surgical safety, efficiency and, in turn, patient outcomes … These developments are the result of effective communication and teamwork between those producing and those using this technology, with variable levels of adoption and success reflective of these partnerships … Competition between various platforms will center around how easily these capabilities can be incorporated into operative workflows and, more importantly, how they augment surgical abilities. Foremost, safety must be ensured. With respect to surgical navigation, accuracy and faithfulness to planned hardware placement is paramount. With regard to robotics, seamless incorporation of imaging guidance into effector placement is key … Thus, in this exciting time, competition will be driven by innovation. In the fields of spine and orthopedic surgery, technology is increasingly being utilized not only to develop new hardware, but also to devise tools which can more safely and efficiently guide a surgeon intraoperatively. Surgical navigation, robotics and smart tools represent the forefront of this evolving arena with surgeons and the industry working together to realize their potential.
On physicians assessing potential workplaces: For spine surgeons evaluating their opportunities, the following are some key questions to pursue:
How is access to operating room time, including whether key specialists are available to support spine surgery, and if the tools to support high-quality spine surgery such as microscopes and navigation technology are available or will be purchased? In an ASC setting if there is a vascular or neurological intraoperative injury, what type of support, transfer mechanism is in place to ensure patient safety
What is the compensation framework, including what behavior is rewarded, and how is productivity measured? If productivity is measured in terms of cash collections, what is the performance of the revenue cycle and how are spine cases reimbursed in the commercial payer contracts relative to market norms? Is revenue shared equally among all providers or passed on work RVUs/collections.
Will the surgeon have the ability to participate in ASC joint ventures, shared savings program benefits for value-based care, and other forms of passive income generation?
How are non-financial terms navigated, including things like pathway to partnership/partnership criteria, restrictive covenants and noncompetes?
How quickly did the last new spine surgeon build his/her practice? What resources are available to support a surgeon building his/her practice? Has any spine surgeon ever left the group and why?