An Enlightened Approach to Hernia Surgery with Dr. Reinhorn and Dr. Fullington

I had a great experience with my inguinal hernia surgery this summer, so I just had to invite my doctor, Nora Fullington and her  partner, Dr. Michael Reinhorn from Boston Hernia onto the podcast!  A few takeaways:

1. The vast majority of hernia repairs are performed by general surgeons in hospital operating rooms. But better outcomes, lower cost, and greater convenience are possible if you can find a specialized practice like I did and go to an ambulatory surgery center. (Only 3% of inguinal hernias in Massachusetts are repaired in ASCs, which is nuts.)
2. Despite the superiority of the Boston Hernia model, insurance companies and big health systems make it hard for patients to go this route.
3. You shouldn't be scared of mesh as long as your surgeon knows what they're doing
4. Patients are often mis-diagnosed with hernias as a result of medical imaging. A physical exam is the way to go
5. Drs. Reinhorn and Fullington believe their model can be applied more broadly within surgery and beyond

Enjoy the show.

As of March 2025 HealthBiz is part of CareTalk. Healthcare. Unfiltered and can be found at the following links:

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Host David E. Williams is president of healthcare strategy consulting firm Health Business Group.

Episodes through March 2025 were produced by Dafna Williams.

Transcript

0:00:01 - David Williams
I had hernia surgery this summer and, surprisingly, it was a great experience, with a quick recovery. And not only that, but it turns out that my doctors at Boston Hernia are pioneering a care model that solves core problems in healthcare: Cost quality and patient experience. So how do they do it, and can the hernia model be applied to the rest of medicine?

Hi everyone. I'm David Williams, president of strategy consulting firm Health Business Group and host of the Health Biz podcast, where I interview top health care leaders about their lives and careers. My guests today are Dr Michael Reinhorn and Dr Nora Fullington of Boston Hernia. Do you like the show? If so, please subscribe and leave a review. Dr Fullington, Dr Reinhorn, welcome to the Health Biz Podcast. 

0:00:55 - Dr. Nora Fullington
Thanks so much for having us. 

0:00:58 - David Williams
It's a great pleasure. We're going to talk about hernias, which is fun, but before that I'd like to talk about how you got to what you're doing now. Often it's one person I'm interviewing, but with two, that can work out as well and I'd like to hear about you know, starting all the way back, what you're comfortable with -- your childhood education and early medical career. Maybe, Nora, we'll start with you. 

0:01:23 - Dr. Nora Fullington
Sure, so I grew up in New York City after my parents and brothers moved from Ireland, so I come from an immigrant background to some degree and grew up with all different people of different backgrounds, different perspectives, different creeds, and it was very enlightening and, I think, empathy building and it really kind of put me in a position to want to work with people. So then, when you know, ultimately I made the decision to go to medical school and get into this field. It was that human interaction that really attracted me, so I went into surgery, trained at UMass and then stayed in Massachusetts afterwards with UMass as a general surgeon and that was really great. I mean, doing all kinds of surgical procedures, taking care of all kinds of problems, was really, you know, both interesting and rewarding. And then I joined Mickey at Boston Hernia, and I'll let him  talk a little bit about that. 

0:02:29 - David Williams
Sounds good. So, Mickey, how about you? Same upbringing, you're from Ireland also? 

0:02:32 - Dr. Michael Reinhorn
Okay, so no, I'm not from Ireland, but I'm probably one of the only Jewish "micks" you'll ever meet. 

I grew up in Israel. My grandparents and my parents emigrated from Europe after World War II. I think my biggest influence growing up was my grandfather, who survived Auschwitz with his wife and became an entrepreneur in Israel. He opened up his own tailor business and my parentswere pretty driven immigrants both in Israel and then into the US when I was nine.

...engineers or kind of role models in terms of hard work, learn and then engineering trade, and so I studied engineering undergrad at Cornell and thought I would design artificial limbs and hips and, through a transformational experience at Cornell, decided to go to medical school instead rather than just engineering. 

And surgery was an immediate love, just because you had the ability to almost be an engineer on a human body and general surgery was one of those things where you had immediate gratification. You really made an impact in people's lives so quickly, so dramatically, and I thought I would spend 30 years being a general surgeon. But I quickly learned that becoming more specialized, especially in the Boston area, was really important to take care of patients, and I saw a gap in inguinal hernia repair, where patients were coming to be injured from other surgeons, and I kind of spent about 15 years learning the anatomy and went so much into it that I actually went back to school 10 years ago to Brandeis to get an MBA to how to transform inguinal hernia care in this country. And then we ended up founding Boston Hernia together with my PA, Lauren, six years ago now. 

0:04:31 - David Williams
Excellent. You know, there are a few Jews in Ireland actually in Dublin and if you ever meet any. They explain to you that when you. You know I never heard of that, but there are actually a few. They call it out. So it could well be All right. So let's talk about hernias, and I want to start off with what happens to the typical patient with a suspected hernia. I know it can go right, but how does it work for the typical patient and what tends to be wrong with it? 

0:05:01 - Dr. Michael Reinhorn
Nora, thank you. 

0:05:03 - Dr. Nora Fullington
Sure, yeah, so I think that's part of what brings me and Mickey to this role, right, nora, thank you. And a lot of times groin pain is treated like it must be a hernia and there are a lot of reasons why people can have groin pain. So first and foremost, it's how do we know that they actually have a hernia? Typically, patients go to their primary care first. They might have an ultrasound or a CAT scan ordered. That is then read by a radiologist and often, if it's read as having you know there being a hernia present, they're then sent to a general surgeon. Most hernia repairs done in this country are performed by general surgeons. That's because we have a lot of general surgeons. It's not because general surgeons are each performing thousands of hernia repairs. So what you end up with is seeing somebody, in most cases who does maybe 50 hernia repairs a year. That surgeon receives this patient, sees an ultrasound report, says okay, pain in the groin, hernia, and then perform the surgery. 

And there are several different ways to do a hernia repair, but most general surgeons have their way. They might have a backup, but they have their way that they do it. Whether that's the traditional open surgery or a robotic repair, they tend to fit that patient into that puzzle rather than the flip. Many times that goes well, but we do know that 5% to 15% of the time patients can be injured, and what we mean by that is there are three nerves that live in the area. There are actually more than that, but the three main ones that get injured are potentially injured when mesh is placed over them, stitches are placed into them and patients can develop chronic pain after surgery which can be significantly debilitating. So, essentially, the typical patient may end up in a situation where they're having a surgery that they may or may not need, depending on if that diagnosis was accurate, with someone who performed surgery for this problem maybe 50 or so times a year and, like we said, most of the time they do okay, but there is this big bad complication that can happen. 

0:07:28 - Dr. Michael Reinhorn
So that's sort of the typical, yeah, and I think I'll add that about one in three patients are probably misdiagnosed when they come into our office because, in our experience, imaging is notoriously inaccurate and a lot of surgeons have not been trained. It's not their fault, but none of us were trained this is all self-taught over the last 24 years of how to really examine a growing and differentiate between a core muscle injury and a hernia, and the treatment is radically different. One involves an invasive procedure, the other one just physical therapy, and we turn away more than a third of patients who've been previously diagnosed with hernia as incorrect diagnosis. 

0:08:12 - Dr. Nora Fullington
I was just going to add one other thing that you know we rely so much on the, on ultrasounds and imaging, because we think they're you know, they're solid, they're 100% accurate. But particularly when it comes to this problem, inguinal hernia specifically, they are often incorrect and sometimes completely incorrect. They can be read as a large hernia when there's actually no hernia. So just when it comes to inguinal hernia, physical exam is absolutely the key. 

0:08:39 - David Williams
You stole my thunder in the sense that I was going to ask about imaging, because when you see something on an image it's very clear. But this is also one of the or it looks clear. But one of the issues, I think, with medicine and costs in general is that back in the olden days, you know they didn't. Maybe they had x-ray, but you know there was a lot more laying on hands and doing this sort of diagnosis by listening or touch and feel, and I think maybe some of just the newer physicians that are trained don't know how to do that. But also the system doesn't necessarily encourage a low-tech approach either. So has this become like more of an issue? So I had my first hernia when I was 17,. I was 40 years ago and then more recently. I don't think in either case I had imaging, before maybe because they didn't do it, and now because I had a good primary care doctor. But what's your sense of that? 

0:09:30 - Dr. Michael Reinhorn
I think it's changed over the last 20 years, I think, as we have more technology available. I think most physicians don't necessarily understand the cost of the technology and don't always understand what to do with the technology. I just recently gave grand rounds at Newton Wellesley Hospital to the primary care department, really teaching them how to do a physical exam. In a way I learned how to do it or self-taught, because I didn't learn it in surgical residency and then I flat out told them to never order a test unless they've referred them to a general surgeon or hernia specialist to talk to and do the exam. Let us order the test if we're confused, because it can lead to a lot of anxiety on the patient's part if they get a misdiagnosis and then they come see an expert who tells them yes, in black and white it says you have a hernia, but I'm an expert and I disagree with that and it opens up to potentially medical legal issues. So I think this is an education gap on the part of the healthcare system. 

0:10:40 - Dr. Nora Fullington
I also think it takes a lot for a doctor to go against another doctor's review, right. So you have to have so much confidence and experience in what you're doing to do a physical exam and say you know what, like that read says hernia, but you do not have a hernia, so it takes a lot. You're asking a provider to kind of put themselves on the line and disagree and say, no, this is what you need. So that's one part of it. I think there's a cost part of it too where we shouldn't be spending money where we don't need it and so we need to sort of, you know, rein that in. Patients come in like ready to go for a hernia repair and it is hard to walk somebody off of that ledge and still have them leave feeling confident that they know what's going on and know what the next step is. 

0:11:38 - David Williams
So it does just really muddy the water big time when it comes to hernias, about so far beyond sort of the expensive and unnecessary use of imaging and misdiagnosis is also if somebody is properly diagnosed and they're having a surgical procedure where it tends to be done. So mine was done in an ambulatory surgical center, which made a lot of sense to me for something straightforward for someone who's in good health. But it seems like I'm only one of the 3% that gets that in Massachusetts. 

0:12:07 - Dr. Nora Fullington
It depends on who you're going to for that care. So most surgeons, in fact in the hospital system that we are affiliated with, almost all general surgeons, do their surgery at the actual hospital, at the hospital, not an affiliated ambulatory surgery center. So it really depends on who you're going to see. Certainly it's like we work for great hospitals, right, we work within great hospitals, I should say, and the care delivered there is really great when you need it, like that's where you need to be. But really it's very nice to have surgery at an ambulatory surgery center. When that's the level of care that you need, it's very smooth, it's in, it's out. The experience, I think I mean you can speak to that, david, but I think the experience is is like going through a well-oiled machine, right it's. It's kind of a nice smooth day. 

0:13:10 - Dr. Michael Reinhorn
So I think you know if you can, if that's appropriate, if the care that you're delivering is appropriate, that's absolutely the way to go. 

So I think I'll add to that and open up Pandora's box a little bit, in that the location of where you have the surgery has to do with your insurance, the employment status of your surgeon and, lastly, your medical need. 

So I think the Health Policy Commission in Massachusetts put out a report a year ago that 3% of inguinal hernia repairs are done in Massachusetts. Nora and I do 2% of that 3% and the reason for that is that we are independent practice we are not employed by a large hospital system, so that if your insurance allows you to have surgery in an ambulatory center, we're one of few practices in the state that can actually triage you toward a lower cost setting that in some cases has been shown to be a lower infection risk than going to a hospital. I would say that probably 80% of the patients that come into our office are good candidates medically to have surgery done in an ambulatory surgery center. But because we have our insurance contracting through Mass General Brigham, we do roughly 80% of our surgeries at Mass General Brigham and only 20% in ambulatory surgery centers, and a lot of that is dictated by the fact that the hospitals get about 80 cents of the dollar on the healthcare dollar, and so practices like ours are a dying breed in some case. 

0:14:42 - David Williams
Got it, so let's start. We've talked about the problems and started to get into the solutions, at least as it relates to the site of care Broadly. How do you see the solution? What's the way that it should be for the typical patient? 

0:14:57 - Dr. Nora Fullington
Go for it. Mickey, I've heard you talk about this really nicely in the past. 

0:15:02 - Dr. Michael Reinhorn
Well, I think the number one thing is the patient's experience right. So I've always taken the lens of, if I was a patient having hernia repair, how do I want to be taken care of? I want to go to an expert facility, an expert practice, where every person along the way is giving me information that's unique to me, that the repair is chosen, what's unique to me as a patient and we built Boston Hernia around that patient experience. First, we have pre-physician assistant candidates who are answering the phone scheduling the surgery, so they're incredibly knowledgeable. They've been in our operating rooms. We have physician assistants who are working in partnership with the surgeons. 

In fact, our co-founder is a physician assistant and she and I took the leap to leave the general surgery practice six years ago because we wanted to set up not just the patient but also the provider experience. When you do that and you put the patient first, everything else follows right. So we deliver higher quality, tailored care. The patient will want to come to a specialist and then we can help determine if there's a better location for one patient or another, and so I think that's completely reproducible. Around any disease entity that's fairly focused, whether it's orthopedics or in GYN, but it involves really rethinking the way we're delivering the care delivery model. 

0:16:41 - David Williams
So one of the things there's a few things you talked about from the patient perspective One is, of course, not walking away with chronic pain, but even the upfront side. You have philosophy in terms of using local anesthesia opioids as much more of the exception than the rule. How does that all play in? How does that? 

0:17:03 - Dr. Nora Fullington
all play in. Yeah, I mean, I think you know, and there's more to it than that too. Mickey talked about tailoring the surgery to the patient right. So part of it is getting it right in terms of what the patient needs. You know, for one of the main procedures that we'll offer to patients involves putting mesh on the inside of the hernia hole. 

So a hernia is a hole in the abdominal wall and we put mesh internal to where that hole is, where the layer of the hole is, so that every time a patient coughs or strains it's planted in that location. That also happens to be away from where the nerves are, so there's less risk of chronic pain. And the way that we place mesh there also allows for avoiding general anesthesia breathing tube, ventilator. So for patients in whom that is an appropriate approach, they can have a surgery that is, you know, the ideal outcome for them in terms of where mesh is placed, that minimizes their risk of complications, that is less stressful on their body, avoiding general anesthesia, and involves the use of local anesthetic that reduces their pain, both during surgery and absolutely after surgery, when we can avoid opioid pain medications. So it's really a tailored package that considers all of those factors to improve a patient's quality of life. 

We think about hernias as a quality of life problem. A lot of times complications we think about are infection, you know, recurrence, which we still consider, but these major surgical site occurrences that are measured by most institutions. They miss the boat on what actually matters to a patient, which is how was their life before versus how was their life before versus how was their life after. And so every time we're making these decisions and tailoring this care, that's the equation we're considering how do we get them back to where they want to be sooner? 

0:18:57 - David Williams
Can we talk about mesh for a minute, because I think most people don't know much about hernias, but everyone seems to have heard about mesh and have an opinion about it, usually negative. 

0:19:11 - Dr. Nora Fullington
Where does that come from and is it deserved? I mean, I think there were problems with mesh as it was manufactured at points right. So now our evolution of what mesh should be and the job it should do has progressed, and so we now know that mesh should really serve as just a scaffold for our bodies to build a scar onto, to create a new strength layer in the area right, Because the hernia is a hole in that strength layer. We want to patch it. It used to be that we just wanted the strongest stuff possible, right, and so your body might ball that up or treat it like a real foreign object and not reject it per se, but not let it do a good job. But now we know that mesh should be manufactured to create that ingrowth and sort of become a part of your body that works with you instead of against you. So now the mesh that is used by the vast majority of surgeons is very safe. 

But there still are problems that can come from using mesh. A lot of times that's directed towards the mesh company, because you know they're an easy target, in some ways relatively easy target. But as surgeons we have to own what we do with these materials. So we've referenced a few times this chronic pain. If we take mesh, put it on top of nerves, ignore those nerves, don't address the anatomy there and sew into those nerves. It's not the mesh that was the problem, right, it's what we did with it. So people can still be injured by mesh, but the safe use of mesh allows for, absolutely in most cases, the gold standard of repair the lowest risk of recurrence, the quickest recovery and really the ideal outcome. So mesh is not bad, but can surgeons do things with it? That's bad. 

0:20:50 - Dr. Michael Reinhorn
Yes, and I'll add to that with a quick anecdote is somewhere around 2015,. 

I reviewed an operative note that I dictated in 2012, 11 years after surgical residency, I did a redo hernia on a patient that had a nerve trapped by another surgeon and I correctly named one out of three nerves in my operative note, 11 years after my training. 

By that point I clearly knew how to identify two out of the three nerves, and it wasn't until I traveled to the Shouldice Hospital, which is sort of the model of surgical efficiency, with hernia, till I learned how to identify that third nerve, the genital branch of the genital femoral nerve. Fast forward, four years later I had two previous presidents of America's Hernia Society fly out to the same surgery center that you went to and they watched Nora and I operate and it was the first time they had ever seen that third nerve. So these are two incredibly respected surgeons who I trust and know, but none of us were taught how to identify the nerves in residency, and so now I sit on the board of surgery and we on the oral exam require the surgeons to at least know how to identify those nerves, and so we're able to change the culture and the education, and so I think this problem is less about mesh and more about surgical education. And you can't throw technology at it, you have to do old-fashioned surgical teaching. 

0:22:28 - David Williams
So let's talk about something that's considered worse than mesh and even chronic pain, which is a healthcare reimbursement system, and I wonder how does the current environment in terms of reimbursement impact your practice? 

0:22:43 - Dr. Michael Reinhorn
So it's the current environment. The traditional insurance model makes our healthcare system unsustainable for anyone right? You look no further than a Boston Globe article where you're interviewed a couple of days ago about primary care doctors and Mass General Brigham. Unionizing the current model 80 cents on a dollar go to the hospital, 10 cents go to anesthesia and 10 to the surgeon. If a surgeon is self-employed, like Nora and I are, roughly half of that goes to paying our malpractice, our rent, our staff, and so that model is completely unsustainable. 

Because we've developed the highest quality care for inguinal hernia surgery, we have had to leave traditional insurance in a lot of cases in order to sustain a private practice. 

Most general surgeons are not as fortunate as we are and have started working for hospital systems as employed docs because that's the only way their salaries can be subsidized. 

And so you know we see our practice as sort of a model of how you transform health care toward real value-based care. We worked on quality for 20 years. In the last six years we've learned how to deliver that care model at a lower cost center, and so I hear a lot of conversations about value-based care and I believe what Michael Porter says. You take the quality of the care, and let's assume our care is identical to everyone else, although our peer review data would suggest maybe it's a little better. And then we can do it at half the cost. And so, for the strict equation standpoint, we deliver twice the value, and I think that we can train other doctors to do this in inguinal hernia, just like Shouldice Hospital has done for no mesh repairs. But we see no alternative other than our practice to be a lab of how to disrupt the current delivery model, both in terms of the quality as well as the reimbursement. 

0:24:50 - David Williams
So you talked about quality and you've got something called the ACHQC. What is that? Why is it important? 

0:24:57 - Dr. Nora Fullington
That's the Abdominal Core Health Quality Collaborative Rolls off the tongue but it's basically a group of surgeons who have come together under the leadership of some of the surgeons Mickey already referenced, who are committed to quality. So the hypothesis with this group is that just dedication to quality should improve our outcomes. And so we, for every single patient that we take care of, we gather data about what how their hernia is affecting their quality of life before surgery and then we follow up with them after, at intervals of 30 days, six months, a year, two years, so that we can we can actually put proof behind what we're saying about how care, how our care, translates to outcomes for patients. So this group has been involved in several different peer-reviewed studies that, each separately, we've all done and worked together. It allows for collaboration, it allows for teaching, it really kind of connects us all through this collaboration to be able to really up the bar in terms of how we provide hernia care. 

0:26:12 - Dr. Michael Reinhorn
Yeah, we have yearly meetings that are quality improvement meeting, where surgeons are giving talks based on their data and we're displaying our own transparent quality data and providing the best model available. So after one of these conferences, I changed the suture material that I use for belly button hernias because there's data out there to say, to use absorbable suture instead of permanent suture. So there's a lot of advances in their real time. You don't have to wait the average 17 years for something to become the standard of care because we collaborate. 

0:26:51 - Dr. Nora Fullington
The other thing that was really cool the last meeting that we had was Mickey brought to the table the cost data too. So we now are kind of pushing the message that when we're talking about delivering value-based care, it has to include all parts of the equation, even the reverse right. Normally it's only talking about cost in sort of the more corporate administrative world, but for us, where we mostly talk about quality, now we're talking about needing to include cost as well and how important it is to have transparency in that area too. 

0:27:24 - David Williams
So I was fortunate that I do have insurance that covered the type of care that was, I think, the most rational for me and lower cost, being in the ambulatory surgery center and covering your services and so on, Although I think you were at the high end of the copay for mine, which wasn't which is not a big deal, but was kind of strange. But I noticed you also have a I think what you call a direct model that is workable even for people if they have insurance, or if they don't have insurance, where you kind of cut that third party reimbursement out of the loop. 

How does that work, and is that a significant part of your practice? 

0:28:06 - Dr. Michael Reinhorn
That was a result of really a lot of years of effort. But the biggest driver for that was about two years ago. Medicare cut reimbursement for one type of hernia that we do 20% of the time to $362 for about an hour's worth of work. And just to give perspective, a couple months ago we're trying to water a new lawn and a faucet broke and so I got a plumber to come in. Within a week he changed a $45 part and I paid $675 for 45 minutes of work. So that's roughly two hernias for Nora and I to do and this guy was here for 45 minutes. 

When we do hernia repair we are taking care of that. Patients under their insurance contracts for 90 days and we worry about them immediately after surgery. We can injure their bowel. There's a lot that goes into hernia surgery. So we came up with what we think is a fair price for our services at $2,250 to fix a hernia. That helps subsidize patients who have insurance or are underinsured in our practice and it covers a lot of the overhead. And while we don't have a written guarantee, I wouldn't ethically feel comfortable charging a patient again in the first year if they came to me with a recurrent hernia, because I know with 100% certainty that if the hernia comes back, it was probably a technical error on my part. Just because I've done this 6,000 times, my recurrence rate has gotten lower and lower and lower the more practice we have, and so I know complications are a result of my technical skill, and when we consent patients, we tell them that we're human out of my technical skill, and when we can send patients, we tell them that we're human. 

Now, being able to deliver a product to patients that's transparent about pricing is super difficult, and in our travels about a year and a half ago we met Mike Havig and the HealthMe team and they developed a product for private practices where they can work with their surgery center, with their anesthesia, and really create a product that's priced prospectively. So when you go to buy a car online, you know exactly what you're getting. When you're coming to our practice to buy a hernia operation, you buy a consultation, you see us and then you pay for the surgery. We don't care whether your hernia is a recurrent hernia, whether we're going to fix it without mesh with mesh, whether it's laparoscopic. We have one price for an inguinal hernia and so we did that initially just through HealthMe, through a direct marketplace so patients can find us online, but also it's for patients who walk in the door that are underinsured or non-insured. And then we also partnered with HealthMe to create what's called Hernia Connect, which is a smaller part of a specialty connect, which is a way to identify. 

What we've done is identified like-minded independent providers like us who deliver super high quality care. We then teach them how to price a health care service prospectively so that a consumer whether it's somebody that's paying for themselves directly as a self-pay patient, or an employer that's fed up with the traditional insurance model of rates going up all the time and said, hey, we've got the ability to navigate patients toward a higher quality, lower cost care and we kind of see that model as being the future of practices like ours, both in terms of sustainability but also in terms of disrupting this incredibly broken model. I think, David, you may or may not have been. We're probably a higher copay for you because my guess is your primary care doctor doesn't work in the Mass General Brigham system. That's right. And so there is a financial disincentive designed by your hospital system and your insurance company to come see us. Yes, they intentionally make us look more expensive to steer you away from our quality of care towards something else, and this is part of what we're disrupting with the direct care model. 

0:32:24 - David Williams
Good, yeah, no, you were hidden. I had to find you, but they let me go because I know how to navigate my way and because my primary care physician is a solid guy, so he wouldn't stand in my way. I want to ask a final question before we actually turn to implications for healthcare more broadly, and it has to do with sometimes, you know, you hear about the triple aim or the quadruple aim, which includes the provider satisfaction, sustainability. You mentioned how physicians are unionizing, which is not what you normally think about and it's probably not what they thought when they're going to medical school that they were gonna do. What is it like as a physician and the kind of practice that you're performing? 

I often hear from people they say you know, I didn't go to medical school in order to, you know, deal with insurance or this, that and the other I want to practice, give my patients the kind of quality you know that they deserve and, of course, to make a living. Is your model one that's good from a physician standpoint or is it, you know, more or less of a burnout than what you typically see? 

0:33:25 - Dr. Nora Fullington
Yeah, I mean, I think, yeah, that's a major issue for a lot of providers right now and I think the system definitely has been hurting us a bit. I mean, I'll speak for myself. Mickey maybe is a little bit different, but I certainly didn't go into medicine thinking anything about business, about cost. I just wanted to take care of people, right, and it was the connection with my patients and the trust that was formed that I found so appealing and that's what drove me and I went to work for a large hospital system where I could continue in that sort of ignorance about how the system works, because they were really supportive, right, they took care of our needs for the most part. 

But you start over time to feel the burdens of the heaviness of a system like that and you hear the whispers of how the you know the budget's in the red and things aren't going well and you got to cut this and primary cares are leaving and the pressures start to seep in. 

And so you know we have to. As people who came into this like wanting to make the world a bit of a better place, it's hard to ignore that the world feels like it's crumbling around you a little bit, and so I think that's that was what drove me to working at Boston Hernia. Yes, I like I went to a very focused hernia model, but it allows in being in a small independent practice, allows a lot more flexibility and this sort of nimble way to adjust to what's needed. And so we right now I think the system is so frustrating and we're so fortunate to work in a practice where we can kind of separate ourselves from that. We can deliver care faster, more efficiently with better outcomes, and I think like it's upsetting to see that happening around us and so many of the primary cares that we work with needing to change and move out of the system and go another direction. But we're hoping to sort of help provide an alternative to that in what we're doing. 

0:35:39 - Dr. Michael Reinhorn
And you know, I started surgical practice thinking that my engineering background will help me identify solutions to technical problem, invent devices to help with surgery. And what I quickly learned is my engineering brain is more of a systems thinking brain, and so I identified gaps in the system and I couldn't leave things alone, and so I've worked for the last 24 years to try to fix the system, both in the way we deliver the care but how we practice. So you know I'm a little guilty of. What my parents taught me is that I work all the time. I don't stop because I'm a small business owner and I constantly see the opportunity to grow. And we're a small practice surrounded by oligopolies who essentially, we compete with Like we work symbiotically with Mass General Brigham, but in some ways we're their competition, and so we're constantly working under some level of stress to stay, to survive, which is kind of the small business owner mentality. 

However, I am fortunate that I absolutely love what I do. When I do surgery it feels like I'm doing my hobby and I am taking great care of patients, and so we're privileged and blessed to be able to do what we do. We do more surgery than most, so we are doing a lot of high volume work. Long term, it would be more sustainable if the reimbursement was to change and we'd be able to hire and train additional surgeons. So we're not working at quite the pace that we're doing so that there would be more of a work-life balance. But in order to do that, the system has to change, and so that's what we're doing. 

0:37:31 - David Williams
So I'm sold on your corner of healthcare. You know hernia can do that. We can make it better for the patient and we can make it work financially for everybody. But that's not all of healthcare I mean. I think I'm hopefully done with hernias I've had too, you know. So the rest of my healthcare is probably going to be in something else. So I want to talk a little bit about the extent to which the approach could be generalized. And obviously nothing is exactly the same as a hernia. But there's other surgical care, there's other parts of healthcare. To what extent do you think that your approach could be generalized for other parts of surgery or healthcare? 

0:38:07 - Dr. Nora Fullington
I mean, one part of it is just assessing your quality and actually knowing what you're doing to patients, right? So there has to be investment among surgeons whether it's through their employer or their own, if they're independent their own investment into actually measuring outcomes, regardless of what the procedure is Right. So we need to know how we're doing and that will inevitably drive better outcomes. So that's in terms of the quality of care. The next sort of piece of this is creating direct care. Bundles can absolutely be applied to many different procedures. It can be applied to inpatient things, yes, but it's especially applicable to surgeries that are appropriate for the outpatient setting and the ambulance, taking that one step further to ambulatory care settings. I think that's the next part of it is as a system we can't sustain. I think that's the next part of it is as a system we can't sustain, you know, doing all of these surgeries that should be in an ambulatory setting, in the hospital setting. It's too expensive and there's not enough room, right? We need more time to do other surgeries and provide other care. So the sort of model absolutely applies to several different types of surgery. I mean, you go down the list of general surgeries gallbladder surgery, you know, sometimes even appendicitis, things like that. You know there are ways to do this in an outpatient setting at a cheaper cost and to sort of assess the likely cost of that care episode ahead of time and have it prepackaged and ready to go. And then, I think you know, making that a more financially possible endeavor for patients, because I think we're as a society, at least in Massachusetts, right, we're so focused and we have to have insurance, right, we can't live without insurance. And I think you know in other parts of the country that is being challenged and it's not wrong. You know there are ways to do this in an effective way without traditional insurance. 

0:40:07 - Dr. Michael Reinhorn
And even direct primary care is a growing alternative to concierge care, where it becomes very affordable and at a price point that most people at $1,000 a year could afford most people at $1,000 a year could afford. 

And it involves really a lot of preventative medicine, because these primary care doctors are spending a lot of time with their patients, really teaching them, coaching them, how to stay healthy and have the lifestyle modifications. Rather than just throwing pills at hypertension, they might address the root cause or maybe treat it through diet, exercise and supplementation and really treat the root cause of the problem rather than just the symptom. The problem is that creates access issues, because in order to spend those time with patients, you need more providers out there, and I think this is where the PA programs and NP programs have really figured it out, because as a team you can take care of a lot more patients in a sustainable way. But I think the biggest, the most important thing is you got to put the patient first. If you put the patient first and really do everything that you can for them, everything else follows because the providers are going to be happy to do that care are going to be happy to do that care. 

0:41:26 - David Williams
I want to ask about technology, because in a lot of parts of society and the economy technology actually helps to reduce costs, improve quality and sometimes substitute for. If there's a labor shortage, you can replace it with technology Somehow. In medicine it seems as though we've got some of these high-tech interventions like robotic surgery you touched on a little bit before you know. Ideally, you could think about how well you could have programmed the robot to do what surgeon could do. You wouldn't need as many surgeons, people could all practice in the same kind of a way, but somehow that doesn't seem to be how it's worked out. What's the role for the robot? 

0:41:58 - Dr. Michael Reinhorn
So let me, I'd love a crack at that. I'm an early adopter of technology. I bought Google Glass the week it came out and used it in the operating room, and when the New York Times articles popped up in front of my eyes while I'm doing surgery, I quickly realized it was going to be more of a distraction and returned it. We utilize right now in Massachusetts. One of the unique things in the state is, if you go to a hospital in Massachusetts, your medical record, including images of your CAT scan, are now available to any doctor on Epic, and so you know, yesterday I saw patients from a different hospital system and I could pop up their entire medical record. So there's certainly huge advances in technology. You know the robotic platform is, I think, exactly what's wrong with healthcare in this country. You know, a medical device company created a product and created a market for that product, and the product is what's really an advanced laparoscopic platform. 

So traditional laparoscopic surgery using long instruments to do the surgery. They created a two and a half million dollar product that takes some of the tremor out of the human hand and enhances the degree of freedom that a human wrist could have, that a really good laparoscopic surgeon doesn't need to perform most procedures. The exception is in a small hole, like in prostate surgery, in hiatal hernia surgery, for example. There are applications where you're working in such a small hole, that really long stick or they call it a straight stick in laparoscopic surgery, which I used to do a lot of, just doesn't work as well. And so for inguinal hernia surgery, for example, we determined that roughly about 5% of patients in Massachusetts would benefit from that technology, usually because they're morbidly obese and that technology is absolutely helpful in getting them the better care that they need. 

But in 95% of the applications it's not. And when I was in business school, we did a study about the impacts of the robot and, with the exception of prostate surgery, the only thing the robot did was increase market competition in areas where there's a high prevalence of robotics. Now, in the last eight years there have been advances and there's other procedures that it can be applied for, but I think this is one of those technologies that's really used best for marketing and not what's best for patients. And in our area we see so many patients who are harmed by robotic hernia repairs, whether the hernia immediately comes back or a nerve was trapped. You talk about value. Here's a technology that costs three times what we cost and has absolutely zero clinical benefit to patients zero clinical benefit to patients. 

0:45:03 - Dr. Nora Fullington
So I'll add to that with just to say that there are. 

To be clear, there are definitely things that robotic surgery is good for right, Like there are procedures, as Mickey said, that it's good for. 

The issue that I think we take with it is that it is pushed as it is the solution to every surgery, that it is the way everything should be performed, and I think that's just overkill. And you ask well, where does that come from? It comes from industry, right, Like that company does better if every surgery uses a robot, and so you have a company that's pushing surgeons to do more and you have a company who's marketing to patients that this is the future and what we want to challenge is not that it's a useful tool, but that it's that marketing. It's that push that is coming from a position that may not be in the patient's best interest. The surgery I talked about is a better approach for most patients to putting mesh in the exact same place and it's, as Mickey said, a third of the cost. That is better care for that patient and there's no industry partner that can tell us otherwise. That is just basic fact. 

0:46:24 - David Williams
So my last question is about patients, and we've talked a bit about what payers could do differently. Maybe you know how physicians are acting, but from the patient standpoint, how should a patient act differently to navigate this system? 

0:46:41 - Dr. Nora Fullington
Yeah, I think it's a tough one, but I think patients are already doing a lot of things, right. You know, like so many of my patients are doing research before they come to see me, and I don't mean necessarily about their medical condition and what type of approach they should have, but research on us, right, like, try to figure out, are we any good? Because you need to assess that Mickey and I both do some consulting. We talk to patients all over the country who are looking for a second opinion, and oftentimes that is the advice I'm giving them. I don't know your surgeon they might be awesome, but you need to double check, right, like you need to do all the research you can do to find out, because not everybody is equal, right, and you want to be in the best hands possible. So I think patients do need to approach their care with sort of that in the background, assessing how good a surgeon is, about their technical abilities and not just their bedside manner, but that too. 

But then also, I think you know I as a patient don't like to go into a doctor's office and they say, oh, I'm going to order you an ultrasound. I don't like to be the person who's like well why, you know, I don't agree. I don't like to be that kind of patient, but I do think there's a way to handle it where we say, well, explain to me, you know, what are we going to get from this? How does that add? You know, is that the right thing? It's okay to question and to try to understand better, and I think patients do that really well. Now. I think we've come a long way in terms of patients really assessing why things are happening to them in their medical care, and so I think, just more of that, more attention and sort of expectation of high quality care. 

0:48:28 - David Williams
Great Well. Dr Michael Reinhorn and Dr Nora Fullington of Boston Hernia. Thanks for taking care of me and thanks for joining me today on the Health Biz Podcast. 

0:48:40 - Dr. Michael Reinhorn
You're very welcome, thank you. 

0:48:43 - David Williams
You've been listening to the Health Biz Podcast with me, David Williams, President of Health Business Group. I conduct in-depth interviews with leaders in healthcare, business and policy. If you like what you hear, go ahead and subscribe on your favorite service. While you're at it, go ahead and subscribe on your second and third favorite services as well. There's more good stuff to come and you won't want to miss an episode. If your organization is seeking strategy consulting services in healthcare, check out our website, healthbusinessgroup.com.