Isador Lieberman, MD, FRCSC, MBA, became President of Texas Back Institute in January 2018, taking the reins of one of the largest and most successful spine-focused practices in the country. The Plano-based group was founded more than 40 years ago and sees around 20,000 new patients per year; the surgeons perform around 4,000 procedures annually.
Here, Dr. Lieberman discusses where he sees the practice growing in the future as well as the biggest challenges ahead.
Q: What is your vision for Texas Back Institute in the future?
Dr. Isador Lieberman: We have a very well-established lineage and reputation in the local market as well as in the national and international markets. We have over 300-plus years of spine care experience, but we can always do better. The first focus is improving patient care to provide the most appropriate and least invasive care whether the patient has a tumor, trauma, deformity or a degenerative condition. The second focus is ensuring the organization is sustainable. There are a lot of pressures out there right now; we all know reimbursement is declining and regulatory hurdles are becoming more substantial and significant. This along with more demanding patient expectations suggests that as a sustainable organization, we will need to adapt.
The TBI team is committed to maintaining our autonomy and are very reluctant to become part of a larger multispecialty group or worse hospital employees. We also continue to be very much involved in the development of new techniques and spine products and we plan to continue affiliations with various entities including large medical device companies and start-ups.
Likewise at TBI we will continue to develop and foster our academic and research focus. We have a strong fellowship program and want to attract the best and brightest to continue making it better. Furthermore we have a dedicated philanthropic international mission component where our surgeons and fellows have an opportunity to volunteer spine care services to the less fortunate in Ethiopia and Uganda. That's a tremendous experience that most fellows don't get with other programs.
Q: Beyond the practice, how do you foresee Texas Back Institute's research entities growing in the future?
IL: We have established a biomechanics and gait lab integrated into Texas Back Institute's Research Institute, which as far as I know of does not exist in any other private practice. We are going to continue studying the gait characteristics of spinal pathology and use those as an objective measure of the outcome of our interventions.
Q: Where do you see the best opportunities for practice growth?
IL: We are strong on the surgery side, but right now we aren't as strong as we should be on the front line of spine care. Our recruiting efforts over the next two years will focus on front-line specialists such as PMR, rheumatologists, endocrinologists for osteoporosis and pain management physicians. We will try to bolster the ranks with these individuals; the surgical core is the engine that drives TBI, but the front line practitioners are the fuel, and the engine will go nowhere without the fuel.
We do have a great reputation nationally and internationally, but locally we need to re-establish our reputation in the competitive and saturated Dallas-Fort Worth market. We are going to shake more hands, knock on more doors and re-engage the various hospital entities, ASCs and other practices to re-energize relationships. TBI is here to help; we are not trying to cannibalize anyone else's practice. Instead, we want to collaborate and improve the spine care of the entire community.
Q: From a business perspective, how does TBI plan to expand upon its strong foundation to create a sustainable organization in the future? Especially as reimbursement declines across the board, but the cost to run a practice continues to increase.
IL: We have to bring in more revenue; we can't rely on reimbursement. We have to focus on ancillary revenue and innovative revenue streams, including possibly international revenue sources, to grow the practice. There are a lot of people seeking our care and we want to provide whatever care they need. We can also advise others on how to improve their practices by sharing with them showing them the mistakes we made and what we did right, or what works in our market.
The other issue we're still working on is optimizing our overhead. We are top heavy right now and we have to make a strategic decision to streamline our operations. I would describe our current EHR as inadequate; I am of the opinion that the EHR should work for us, not us working for the EHR. We need a system that improves the efficiency of patient flow in our clinics and supports top line revenue.
However, we don't want to constrict individuals or mandate practice methods; as we have grown, we've successfully adapted to individual physician practice methods. That reflects positively in our diversity but does absolutely increase overhead. At some point we'll have to draw some boundaries and optimize each location.
Q: What do you see as the biggest challenge right now? What keeps you up at night?
IL: Recruiting the right people. You have to find individuals that truly subscribe to and adapt to the TBI philosophy of providing the best possible care, establishing and maintaining the organization and providing practice satisfaction to each individual surgeon. We want individuals who come on board this ship and help drive the ship in the same direction, regardless of whether they're millennial surgeons right out of fellowship or senior surgeons with great depth and experience.
It's hard to know whether you've found a great fit until you've actually worked with the individual and gone through the trials and tribulations of practice. It's the same dilemma of college recruiters for athletes; someone might look good on paper or in the gym, and they'll excel at times, but they'll also flop. You have to use your gut instinct and figure out from the mentor who trained them whether they subscribe to the philosophy we are looking for. Then you have to put together the attractive recruitment package.
Q: What are your goals for TBI in 2018 and beyond?
IL: This is a regrouping and restructuring year; it will be a heavy recruiting year. We want to attract a number of front line spine practitioners. By 2019, we want to be in full swing, really start rolling, and hopefully our year-end numbers will reflect the fact that we have become more efficient and our patient outcomes have been optimized. We want to see the fellowship program really thriving and make sure academic productivity is maintained or better than it is now. In 2020 we will begin a second hiring phase to complete two-year incremental growth. Then in 2021 we will see the maturation of our recruiting efforts. That's how I see TBI growing, maintaining and sustaining.
We are going to need some more help with the gait and biomechanics lab as well — we're looking for two researchers. We will also try to move some of our in-house billing and perhaps even create an in-house legal team. There are advantages and disadvantages to each; we have become a corporate entity with a small group philosophy, but it's clear that if we do want to bring overhead under control, we have to limit external expenses so we may look at bringing some of the nonclinical administrative components in-house.
We have a strong established marketing department and we will continue to support their work. They are in-house and that's the model we will look at for our other departments. I figure if we are contracting with someone else, they are making money off of us; why don't we do it ourselves? If we sent our marketing efforts out, our marketing budget would be double than what it is in-house.
I am looking forward to all these new exciting changes over the next few years. As spine care practitioners, we are in a privileged position; there are so many tools at our disposal, but there is also much more we can learn and develop. We have many patients that need our help and the opportunity to care for them. It's an exciting time, and despite the nay-sayers I'm bullish on where we are going. I'm not intimidated by negativity or competition; we're going to establish our plan and execute strategically to achieve our five- and 10-year objectives.