The Rothman Model

Written by John J Mangan MD1, Wesley H Bronson MD, MSB1, Nathan A Snyder BS1, Mayan Lendner BS1, Christina Vannello RN, BSN1, Taolin Fang MD1, Mike West MBA, CPA1, Alexander R. Vaccaro MD, PhD, MBA1 | January 28, 2019 | Print  |

This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World "edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.

Over the next several weeks, we will be looking at various spine care models around the US. In the next two chapters we will be looking at the Rothman Orthopaedic Institute model.

Introduction

The Rothman Institute is a world leader in the field of orthopaedic surgery and musculoskeletal care located in Philadelphia, Pennsylvania. The practice was founded in 1970 by Richard H. Rothman and from its inception has been dedicated to being a national leader in musculoskeletal innovation, clinical care, education and research. Today, the Rothman Institute has grown to include one hundred and sixty-five operative and non-operative physicians as well as over forty-five physician extenders in over thirty office locations across three states. Additionally, the practice has expanded its operations to include physical and occupational therapy, radiology including MRI and CT, as well as a full-service prosthetics and orthotics department.

The institute employs a “privademic” practice model which affords its members the benefits of private practice as well as those of a tertiary academic medical center which has helped recruit expert surgeons in all orthopaedic subspecialties. Practicing the highest quality patient centered care is the main drive of the Rothman Institute. As such the practice has strived to bring expert care into local urban and suburban communities.

Education, research and innovation are core aspects of the mission of the Rothman Institute. The practice trains 56 orthopaedic surgical residents and fellows each year. The faculty take great pride in educating men and women to not only be proficient surgeons, researchers and innovators but also engaging members of their communities. The research division of the Rothman Institute employs 60 full-time researchers and encompasses both clinical and basic science research facilities. Every year, research from the Rothman Institute leads to change and advancement in the practice of orthopaedic care in multiple sub-specialties.

Privademic Model

The Rothman Institute (RI) combines the benefits of a private practice model with an academic institution. The “privademic” model has proven successful in providing physicians with the advantages of a private practice while also enabling them to contribute to high-quality literature, discoveries, and innovation commonly associated with academic institutions. These qualities make the privademic model attractive for physicians, insurers, and patients.

The benefits of a private practice remain present in The Rothman Institute’s privademic model by providing surgeons and practitioners with the opportunity to become shareholders in the practice. This makes it possible for partners to supplement declining reimbursements typical of today’s market with diverse sources of income. Initial compensation packages can remain on par with or exceed the compensation offered by hospitals and academic medical institutions. Potential salary growth is another attractive characteristic that sets privademic practices apart from other employment options.

Ownership increases physician autonomy, reduces administrative barriers, and provides physicians with the ability to select their partners and staff. Many physicians operating under the umbrella of an academic institution or hospital are limited in their ability to influence their work place. This is mainly attributed to administrative oversight that limits and obstructs the way necessary changes are made. A partnering physician in a privademic practice has the freedom of making timely changes that improve the patient experience and the physician’s work environment. Ownership in the practice also opens doors to shareholder opportunities in real estate, ambulatory surgical centers, and specialty hospitals. These opportunities supply partners with the ability to diversify their sources of income and makes practicing in multiple markets possible.

Flexibility in physician roles within the practice allows for negotiation of compensation based on clinical and academic factors. This allows participating physicians to choose their level of involvement in clinical and research. Partnering physicians are able to keep royalties, intellectual property, and professional consultation fees they have earned. This removes the barriers to additional compensation commonly found in a hospital or academic model, and thus further drives innovation. These incentives encourage physicians to develop and run research studies while maintaining a full clinical schedule.

The privademic model provides physicians with the opportunity to participate in research and education. Forming relationships with hospitals and academic institutions creates access to teaching residents and medical students. Physician mentorship provides value to residents as well as physicians who experience greater job satisfaction while instructing. Privademic practices support an environment that is amenable to engaging in clinical and basic science research, helping physicians remain current with recent literature.

The “hub and spoke” model utilized by The Rothman Institute connects satellite community practices to a central academic center. This strategy allows for the physician group to establish relationships with healthcare systems outside of the central market. Forming satellite practices increases competitiveness across markets and lends itself to wise allocation of resources. This model also provides physicians with options to refer patients to multiple locations which can optimize quality of care and cut down on unnecessary expenses. Having the flexibility to direct less complicated surgeries to lower-cost ambulatory surgery centers while referring complex surgical cases to higher-cost academic hospitals benefits providers, payers, and patients. Additionally, privademic practices have the ability to keep department resources and income within the department that secured them. Departmental funds enable highly productive departments to continue producing high quality research and promote growth. This ultimately allows the department to spend money where it is deemed necessary.

Another benefit of the privademic model is its ability to allow integration of technology and devices by reducing administrative barriers. The lack of administrative barriers commonly found in the hospital model allows physicians to expedite adoption of new technologies, processes, and protocols. Partnership in the practice improves a physician’s ability to adjust policies by having a direct voice among colleagues in the physician group.

Privademics is a developing practice model that boasts all of the benefits found in private practice while incentivizing physicians to pursue research and innovation. While healthcare is constantly evolving, large privademic practices have the ability to adapt through these periods of change. Reducing administrative barriers, forming relationship with multiple healthcare systems, and incentivizing physicians to conduct research, distinguishes this model from the alternatives. Privademics has proven to be a competitive model that improves patient experience while simultaneously achieving clinical and research excellence.

Philosophy and infrastructure

The infrastructure and practice design stems from the Rothman Institute’s mission to provide patient centered, value- based care. In order to optimize both practice efficiency and the patient experience,we have streamlined both patient care and business practices. The business and clinical departments work synergistically together.
The constant drive to become more efficient allows the practice to lower costs, improve profitability and improve patient experience.

The business infrastructure of the Rothman Institute utilizes metrics and real-time analytics to develop business solutions and make decisions. The operations of the practice are constantly being evaluated by metrics which objectively assess each department. The metrics are used to populate a scorecard for comparing how the practice is performing compared to its benchmarks. Patient outcome data, as well as other clinical data, are included in several of these business algorithms such as length of stay, complication rates, and infection rates, among others. These clinical data points are critical in risk stratification and forecasting models that provide valuable data for creating the practice benchmarks and financial forecasts.

An integral part of the philosophy of the practice is transparency and equality. All physicians and surgeons in the practice are provided with the same base contract. The practice publishes its departmental scorecards regularly and shares them with all stakeholders. This stakeholders with an up-to-date analysis of the overall performance as well as each physician’s performance. Partnership is available to surgeons and non-operative physicians who fulfill the financial and academic requirements of the practice.

In today’s healthcare climate, it is essential for surgical practices to understand how they are performing from both a business perspective as well as from the perspective of patients. The Rothman Institute has been heavily invested in understanding how their patients view them as well as the clinical outcomes of their patients. As part of this commitment, the practice has used innovative software that collects and categorizes patient survey data on their treatment experience as well as on preoperative and postoperative outcomes. This information enables the practice to gauge the effectiveness of their surgical and non-surgical interventions and helps target where changes can be made to improve the patient experience.

A perfect example of the synergistic relationship between the business and clinical departments of the Rothman Institute is the method that the practice utilizes to risk stratify patients. This algorithm allows for each patient’s individual needs, comorbidities and surgical risk to be considered and steers providers into choosing the appropriate treatment setting. The Rothman Institute has strategically aligned itself with several different surgical facilities and is able to maximize the care provided at each. For example, patients undergoing a microdiscectomy with a history of myocardial infarction or pulmonary embolism maybe risk stratified to have their procedure at the tertiary hospital. On the other hand, a young healthy patient undergoing a microdiscectomy may be better suited for surgery at their orthopedic specialty hospital. This method of risk stratifying patients lowers the overall cost of care for patients, providers and insurers and results in higher patient satisfaction. As more orthopedic surgerytransitions to outpatient surgical settings, it is critical to understand the patient care and financial risks associated with these decisions. The Rothman Institute has a taken a proactive approach in making these decisions to optimize patient safety and cost effectiveness.

Another area of focus for the Rothman Institute is their call center. For most patients, the call center is the first contact point with the organization and in many ways affects their perception and experience at the practice. Substantial resources, training and close monitoring are provided to the call center. The call center employees follow clear algorithms in order to ensure patients seethe most appropriate provider. This allows the patient to have a better experience as they are able to get the appropriate care they are seeking in a timely manner. It also benefits providers, as their time is maximized by only seeing patients that may need their expertise. This is particularly important in the spine division where the call center will help sort which patients require a non-operative or operative physician.

In the next chapter we will be looking at Research and Innovation at The Rothman Institute.

Previous chapters:
Challenges, risks and opportunities in today's spine world

Spine care - Balancing cost with innovation

What are big data and predictive analytics

Predictive Analytics and Machine Learning

The HSS Spine Care Model, Part 1

The HSS Spine Care Model, Part 2

 

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