How South Dakota's newest spine group finalized a merger & plans to establish a Center of Excellence

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Rapid City, S.D.-based Black Hills Orthopedic & Spine Center and Black Hills Neurosurgery & Spine merged Sept. 1 to form The Spine Center at Black Hills Orthopedics, a 20-physician group that includes five spine surgeons and one neurologist.

Jim Shea, spine center director at the newly formed entity, aims to integrate the group more closely with its surgical hospital partner and create a Center of Excellence for spine.

Mr. Shea spoke to Becker's about the strategy behind the merger, addressing challenges when consolidating and how the practice plans to compete in the future.

Note: Responses are lightly edited for style and clarity.

Question: What was the strategy behind the merger? How long had it been in the works?

JS: We've had informal discussions for a number of years. They were generally hallway conversations between physicians or discussions between me and the CEO of Black Hills Orthopedic about the concept of combining our two groups. The thought process was that our group — a neurosurgical group that primarily did spine surgery — chose to go down that specialty path a few years ago, so the majority of the work our physicians did was spine surgery. Black Hills Orthopedic has three orthopedic spine surgeons and our two groups had a very strong connection via Black Hills Surgical Hospital, where our surgeons do most of their work. As we worked together in that surgeon-run facility, our physicians had a lot of contact and discussions naturally occurred. 

It made a lot of sense because both groups do spine surgery and we are linked via Black Hills Surgical Hospital. We began having more earnest discussions about the possibility [of the merger] in the last year. A lot of it was promulgated by outside things happening — industry changes, changing payer requirements, requirements to get more involved in value-based pricing and value-based care. It made more sense to do it together than apart. We were in a unique environment because while we were partners in the same facility, we were also competitors. In order to create a patient-centric facility, we thought we could do it better with combined resources. It gets harder and harder every year for smaller groups to do the things necessary to stay relevant. So, looking at this as a larger organization, it helps us bring the resources necessary to create some of the things we need to develop this center.

Q: Why did you choose this year to combine practices?

JS: There's been increasing pressure from outside influences such as government regulations, payer requirements, more payers looking to value-based and quality programs, or pricing like the value-based purchasing program CMS did. We were a busy practice, but a much smaller group than the orthopedic group. If we wanted to grow into doing things we have to do to stay relevant in the industry, we needed to be able to expend greater resources. You're seeing that nationwide, with more and more practices merging or joining with hospitals so they have the resources to do the things that are now being required by these outside influences. It takes so much more resources in IT, staffing, equipment, etc. There's more and more every year we're required to expend money for to stay in the game.

Q: What steps did you take to facilitate a smooth merger of the two groups?

JS: We started by sharing confidential information so we could see what each practice looked like. We had meetings with leadership of both entities. In our case, we only had our two neurosurgical owners. We talked about philosophical things such as how we wanted to practice together, future intent and long-term goals. We started doing that in earnest in December/January 2019-20. When COVID hit in March, everything stopped. Everybody concentrated on their own practices and began working with government programs such as the Payment Protection Program. As things got closer to reopening, we started talking again. I think it was the fact that there was such a significant change in the environment that we said, "let's do it."

We struck a deal quickly, then it was about a three-month process of integration. Myself and the executive team met on a weekly basis to go through items we had to get done before Sept. 1. We all generally agreed that the first three months was the time to make sure we did everything right and took care of things that popped up after opening. Things that you didn't anticipate and fixing things that you thought were going to go well that didn't. From Sept. 1 until the beginning of December, we've been smoothing things out, making things work well and working on policies and procedures that work better together then apart. For the start of the new year, I'm focusing on what they hired me to do, which is to develop a comprehensive integrated multidisciplinary spine center. We're going to embrace value-based Center of Excellence types of programs.

Q: What were some of the hiccups you encountered while merging the two groups?

JS: Number one would probably be IT. EMR is changing constantly. When you go from one system to another, it's amazing how difficult it is for people to acclimatize to a new system after using another system for so long. It was even more different because we stayed in our facility, so you stopped working as Black Hills Neuro on Aug. 31 and reopened Sept. 1. We went from doing things one way to a completely different way the next day. Concentrating on that is very important to make sure you get those bumps smoothed out quickly. It took several months to do as there's so much involved in working with an EMR.

Also, hierarchy. Knowing who to call and who to work with when a problem arises and needs to be resolved. You're going to have a new organizational structure to get used to. We had ours, they had theirs. In essence, we created a new one. We had input from both directions and worked through some differences. Who reports to whom? Who is supposed to do certain tasks done by one group prior to the merger and another group after the merger? Another big one was the patients and customers, referring doctors' offices. We had two phone numbers. Doctors and patients were used to calling our phone number at Black Hills Neurosurgery. We kept both numbers live and linked them.

Additionally, teaching schedulers who make appointments for the orthopedic surgeons to make appointments for neurosurgeons. You must teach them scheduling parameters and protocols. There's also patients who are confused because they don't know the difference between the old group and the new group. We spent a lot of time on how to let patients know — web notices, email, text messaging, patient reminders, letters. 

Q: Did you encounter much resistance to this change?

JS: We didn't have any physician resistance to the buy in. We had three physicians when this started — two neurosurgeons and a neurologist — and reached out after the COVID period to see if we could get this going as a group. There was obviously physician discomfort in the changeover, mostly in terms of learning new systems. For example, if you're changing to a new EMR, the first thing you do when you start clinics is cut them in half. You see less patients because you know it's going to take time to get used to the new system, so we had smaller patient volumes initially so our doctors could get used to the system and still get over to the hospital to do surgery.

It's a big change, but I think we did it very well. Especially with our five spine surgeons because they have formed a very good relationship, which is interesting because they're orthopedic spine and neuro spine. They generally do the same thing, but they don't practice completely the same way. They still do the same basic surgery, but they approach it from different directions based on their training. They also see patients a little differently based on their training and experience.

Q: How have the spine surgeons been collaborating in the new group?

JS: They work together in our physician work areas, sharing cases with each other, asking for opinions, helping each other in surgery. We have regular spine physician meetings each month and often they talk about the way they practice and how they want to do things. One of the big things we're discussing now is standardization — everything from the way we run our clinics to intake forms, whether they're electronic or paper. We've identified that as one of our priority items: standardizing a lot of the things that can be standardized very easily, despite everybody agreeing to a certain format.

Q: What's next for your group? What are you most looking forward to?

JS: The next step is to work together as a spine center with Black Hills Surgical Hospital. We plan to create a Center of Excellence for spine, a mutual venture between the hospital and our group. We want to fully integrate all aspects of spine care, to align more closely with the primary care sector of our marketplace as well as other specialists and providers who can add value to our center. We want to embrace what's changing in the marketplace, especially in terms of quality and value-based care. We're very good at surgery; that's what we do. But we want to work on the nonsurgical aspect of our center. We want to make sure we don't miss out on a big opportunity, which is nonsurgical care. We aim to align more closely with individuals who provide that. We're talking to them about crafting improved patient pathways and improving the overall patient experience.

We want to improve patient pathways, not just during surgery but even before the first call to the office. Many patients don't know how or where to call when they have a problem. Our goal is to build a center that will provide that. The other part is to help lower healthcare costs. When you integrate and combine groups, you can provide care together that's more streamlined. You can take a big bite out of that by improving how patients get care — the right care at the right time. We're developing a closer relationship with our hospital to streamline things such as EMR. A lot of the transfer of data and information sometimes ends up being done manually. Our hope is to make those things more automated so we can improve patient pathways, clinical outcomes and all the things we're being asked to do right now by outside forces. 

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