The Doctors’ Lounge
Where scalpels meet systems — and physicians say what they really think.
Co-hosted by Anish Koka, MD & Anthony DiGiorgio, DO. Candid talks on healthcare policy, reform, physician autonomy & patient care.
The Doctors’ Lounge
Outpatient Brain Surgery: How Buffalo Built America's Only Neurosurgical ASC
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The Doctor's Lounge
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Episode Summary
Anish and Anthony are joined by Dr. Elad Levy — Professor and Chair of Neurosurgery at the University at Buffalo, holder of the L. Nelson Hopkins Endowed Chair, and one of the country's most prolific physician innovators — for a wide-ranging conversation on how he and his partners built Atlas Surgery Center, the only physician-owned outpatient neurosurgery center in the United States, now performing roughly 3,000 cases a year including outpatient angiograms, carotid stenting, brain aneurysm treatment, gamma knife radiosurgery, and complex spine work. Dr. Levy walks through the operational efficiencies that let four staff do the work of fifteen to twenty in a hospital, the negotiated device pricing, the inclusion/exclusion criteria for outpatient cases, the constraints of Medicare's inpatient-only list, and why payers have embraced the model at 90% of hospital rates. The conversation also traces his personal arc — from rowing at Choate and Dartmouth, to neurosurgery training at Pitt, to fellowship under Nick Hopkins in Buffalo — and the field-defining work he and colleagues did to establish mechanical thrombectomy as standard of care in the 2015 New England Journal papers, plus his current work on endovascular brain-computer interfaces with Synchron and ongoing conversations with Neuralink. The episode closes on neurosurgery workforce challenges, the alternative pathway to board certification for foreign-trained surgeons, and why physician ownership may be one of the most underrated levers for rural access to specialty care.
Chapters
00:00 Welcome and introducing Dr. Elad Levy
01:05 The origin of Atlas Surgery Center: outgrowing the hospital
03:14 Relationship with the hospital system and how the partnership works
04:36 SUNY Buffalo, Kaleida Health, and the Atlas LLC structure
06:44 The collective pain points that drove physician ownership
07:30 Personal journey: Israel, Italy, and rural northern New York
08:14 Choate, Dartmouth, and varsity rowing
10:35 Med school, Pitt residency, and falling for neurosurgery
12:24 Fellowship under Nick Hopkins in Buffalo
14:42 The thrombectomy revolution and the 2015 New England Journal papers
16:30 "If I had a tomato, I would throw it at your face" — early endovascular pushback
18:03 The COMMAND trial and endovascular brain-computer interfaces with Synchron
19:43 Neuralink, Precision, CoreTech, and the Wright Brothers phase of BCI
22:07 What can move outpatient: angiograms, aneurysms, stenting, functional, spine
25:52 Why ASCs are cheaper: device pricing, staffing, and turnover times
28:20 Reimbursement at 90% of hospital rates and the case for site neutrality
30:23 Inclusion and exclusion criteria — the "is this your mother?" test
31:50 Medicare's inpatient-only list and why it locks patients into hospitals
34:35 Financial ethics of physician ownership versus corporate medicine
39:53 Could Atlas become a physician-owned hospital? The two-midnight rule
41:43 Everyone goes home at four — efficiency as patient access
44:27 The hospital industrial complex and regulatory drag
45:13 IRB and clinical trial speed in an ASC: weeks versus a year
46:29 Neurosurgery workforce, foreign medical graduates, and the alternative pathway
50:32 Buffalo as a city of good neighbors — and physician retention
53:38 Vetting international training and what board certification really protects
55:03 Grey's Anatomy, McDreamy, and the Dartmouth rowing connection
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Anthony DiGiorgio: right. Welcome to the doctor's lounge. We have a special guest tonight. Dr. Levy is professor of neurosurgery and radiology at the Nelson Hopkins professor and chair of the department of neurosurgery at University of Buffalo. I consider one of the more interesting physician innovators in the country. He's really sitting at the intersection of high-end neurovascular care, physician ownership and site of service disruption through the Atlas Surgery Center in Buffalo, New York. Atlas is pushing the boundaries of outpatient neurosurgery, including complex cerebrovascular and tumor work, and has drawn national attention for procedures like outpatient carotid stenting. Most doctors complain about the system, like we are accustomed to doing here, but Dr. Levy, you actually built an alternative. So what do you see in hospital-based neurosurgery that made you decide to create a physician-owned ASC in Buffalo?
Elad Levy: Well, first, thanks for having me. And I think that's a great question. I'll tell you, if I may, a little story. So when I became chair, we had nine attendings here in Buffalo. We grew the department to over 20. And when you try to cram 20 neurosurgeons into the space that was barely adequate for nine, you're going to have bottlenecks. So we have young attendings with young families starting elective cases at 9 PM on a Friday, or on a Saturday, or on a Sunday. So when I became chair, we had nine attendings here in Buffalo. ⁓ We grew the department to over 20. ⁓ And when you try to cram 20 neurosurgeons into the space that was adequate for nine, you're going to have So we have young attendings with young families ⁓ starting elective cases at 9 PM on a Friday, or on a Saturday, or on a Sunday. with hour plus turnovers, not sustainable. Not sustainable for more volume, not sustainable to meeting budget. So we came to the hospital and we said, hey, there's many things we do we can move outpatient. So we know in the spine world, lumbar laminectomy, anterior cervical discectomy, some other spine, but we can move angiograms outside. They go home the same day. And potentially some functional neurosurgery. And decompress a hospital, give more block time. with hour plus turnovers, not sustainable. Not sustainable for more volume, not sustainable to meeting budget. So we came to the hospital and we said, hey, there's many things we do we can move outpatient. So we know in the spine world, lumbar laminectomy, anterior cervical discectomy, some other spine, but we can move angiograms outside. They go home the same day. And potentially some functional neurosurgery. And decompress a hospital, give more block time. hospital wasn't interested. Follow-up question, do you want to do a joint venture? Will risk not interested? Final question, do you mind if we do this ourselves? And you would have thought I gave a Rodney Dangerfield monologue with the laughter. But they gave us permission, so we identified some land near one of our office buildings. And two and a half years later, we're doing 3,000 cases a year. hospital wasn't interested. Follow-up question, do you want to do a joint venture? Will risk not interested? Final question, do you mind if we do this ourselves? And you would have thought I gave a Rodney Dangerfield monologue with the laughter. But they gave us permission, so we identified some land near one of our office buildings. And two and a half years later, we're doing 3,000 cases a year. We have some of the highest physician satisfaction ratings of any department in the hospital and certainly higher than we've ever had as a department. We have some of the highest physician satisfaction ratings of any department in the hospital and certainly higher than we've ever had as a department.
Anthony DiGiorgio: I can, I can certainly relate to those, those start times and I don't know, an hour turnover is a, would be nice. Sometimes I wish it was that quick, but that's, I think that's, that's an incredible story. ⁓ go ahead. ⁓
Anish Koka: Wow. Did, did, so this was kind of in partnership with the hospital. Do they have ownership of, part ownership of the land or part ownership of the, does that ⁓ work? It sounds like ⁓ is not like an antagonistic thing. This is something that's ⁓ done together.
Elad Levy: So no, but we came from a very good place. So we have a phenomenal relationship with our hospital partners. Buffalo is a small community and rising tide raises all ships. And we want a strong hospital partner makes a strong neurosurgery department. So we approached the hospital and perhaps it wasn't the right time or maybe they had other commitments or another vision, but they gave us permission to do this ourselves. So there wasn't a hostility or ⁓ ⁓ antagonistic sentiment. We said if you don't want to do it, can we do this? we did this. And ⁓ after opened, we put in the first outpatient privately owned gamma knife. We had the busiest gamma knife unit in the United States. So Buffalo had one. They were doing ⁓ many, hundreds of cases, more than the sweet spot. Again, we approached the hospital partners and said, is there any interest in putting a second gamma knife unit in this town because of the volume that we've now built. No interest, so against all odds, we got cobalt and we put a gamma knife now. So we're doing radio surgery, intervention, diagnostics, functional neurosurgery, obviously spine, and some soon to be basic craniotomies.
Anish Koka: So to be clear, to elucidate, you are the chair of neurosurgery at SUNY Buffalo. ⁓ hold the Nelson Hopkins endowed chair, ⁓ ⁓ the hospital and you ⁓ ⁓ department of neurosurgery for the hospital. They have their own neurosurgical department.
Elad Levy: Yes. Yes. Yes. Correct, so just sort of expand. So the University at Buffalo, SUNY Buffalo, Jacob School of Medicine, we are the Department of Neurosurgery. I'm the chair of that department and we have about 21 or so neurosurgeons and some other ancillaries. The hospital system, Kaleida Health and other hospitals in town, are with the university but are two different entities. We are the predominant
Anish Koka: Yeah.
Elad Levy: service line for that hospital, right? That's where all the residents train. I'm the director of neuroscience for Collider Health. So two different hats. And then Atlas Neurosurgery Center is the same. We have the same physicians that are in the department, but under a separate LLC, a separate corporation, independent from the university, independent from the hospital system. That's very important.
Anish Koka: Okay. So you run the residency program for hospital. that ⁓ the university? Sorry, for the university. Yes.
Elad Levy: for the university. I guess, guess you're giving me dollars to throw through the hospital. So you're correct. So yeah, we are the department that trains the residents. We have three fellowships, endovascular functional spine, multiple fellowships in spine. train three residents a year. We train four or five endovascular fellows a year. So it's a, it's a busy shop and a little bit of a proud moment. I think in 2023 or 24, J &S published our volumes as one of the highest volume academic neurosurgery programs in the United States.
Anish Koka: Wow, that's incredible. was this, you used the we, when you were talking about wanting to do this and set up shop and stuff. How many of there were you and, or was it just you who kind of approached it? Can you speak a little bit about how that happened?
Elad Levy: So honestly, I think it was a collective sort of pain that we were having. We were having a lot of pain points. And by no fault, I certainly don't want to blame the system, the hospital system. It's just when you grow a department, Nick Hopkins built UB neurosurgery. And then when I became chair 12 years ago, we took it from nine to 21. So we need more room and space. So I think the collective pain points, many of the physicians said, if they're not going to do this, let's do it ourselves. And Doug Moreland, one of the partners, is the energy behind this. He's very entrepreneurial and really helped drive this. He sort of was the point person who made this happen for us.
Anish Koka: Before, going to get into some of the stuff, but thought we'd remiss not to talk a little bit about your personal journey to this point. Can you tell us a little bit about, ⁓ I understand father was an Obigine, is that right? You weren't born in the US, you were born in Israel, is that correct?
Elad Levy: That's right, I was born in Israel and spent some time in Italy while he was in medical school in Bologna. So he was a pro soccer player, not a good one. So that was a short career and he wanted to actually go to be a veterinarian. He wanted to go to a vet school, but his grades were so poor that in Italy it was too hard to get into vet school. So he went to med school. Eventually finished school and came, we moved to New Jersey and
Anish Koka: Ha ha!
Anthony DiGiorgio: Ha!
Elad Levy: not a lot of jobs there, he basically used his Italian to get construction jobs and eventually landed a residency, wanted to be an orthopedic surgeon, but landed a residency as an OBGYN. We moved to Northern New York, rural, rural New York, just south of the Canadian border. after a few years there ⁓ education, they sent me to a boarding school, Chote Rosemary Hall, I think. ⁓ sort of learned to row there and talk about this bloody hand. that was, you know, I pulled that oar like that was my lifeline. I this is my way into a better world. And eventually recruited to row at Dartmouth where I rode for four years and after that med school and then neurosurgery at Pitt.
Anish Koka: Wow, so you were a varsity college rower, my goodness.
Elad Levy: Yeah, I wrote for the US under 19 team in France at Junior Worlds and survived four years of Dartmouth rowing and had illusions or delusions of making it to the next level. that wasn't in my destiny.
Anish Koka: That is... ⁓ my god. Wow. I briefly get on the erg every now and then, so I'm already now... That is more impressive to me than anything you've done with this ASC or this chair of neurosurgery. When did the ergs start coming out? Did the ergs come out like in the last 20 years or so? I when you were rowing, did they have ergs or no?
Elad Levy: I'm They did. they had sort of early generation flywheels. I was a chote from 1987 to 1989. And I tell the story that I'd wake up at six in the morning and again, no one's driving this. I try to tell my kids this, but you got to want this. I'd wake up, run down the hill to the gym, wait for them to turn the lights on, row on this early generation flywheel that had a tachometer. Like, you know, it was like a bike wheel and you just see the tachometer turn. barely make it back in time for French class, which was my first period, fall asleep through French class, wasn't great. then get back to practice and try to get to practice at the end of the day. Larry who was a coach at Dartmouth, saw something in me and said, hey, you want to roll for us at Dartmouth? I'd love to.
Anish Koka: amazing, that's awesome. ⁓ trajectory then took you to ⁓ my hometown where I grew You did residency in, guess, neurosurgery residency there. Is that right?
Elad Levy: Yeah, so when I was at GW in DC, again, I wanted to go to med school work at Still Row, so I was trying to row 5 o'clock in the morning on the Potomac with Potomac Boat Club, and I'd walk into class still dripping wet and... My sneakers, I remember, were tied to my backpack and there'd be one seat in the middle and as I walked I'd hit, not on purpose, my sneakers would hit all the students in the head as I'm trying to go. I'd sit down and open a can of Bush's baked beans as I try to eat that for breakfast while I'm trying to listen to biochem shortly which after I'd fall asleep I tell my friends, don't let me fall asleep, I need to hear this lecture. Fell asleep.
Anish Koka: So Dr. Georgiou, this guy, Dr. Levy, he would be most likely to become a neurosurgeon, ⁓
Anthony DiGiorgio: Yeah, real underachiever like most of us.
Elad Levy: Yeah,
Anish Koka: enjoys enjoys pain to a significant degree. Yeah.
Elad Levy: So how do I get into neurosurgery? I applied for orthopedic summer fellowship. You know, they have those first year, second year summer fellowships. First choice orthopedics, second choice neurosurgery. Didn't get the ortho, got the neurosurgery. And Dr. Shaker at the time was a chairman, so skull-based tumors. am serious when I tell you for two years, I thought the most common neurosurgical procedure was a petroclival meningioma, followed only by redo petroclival meningiomas.
Anthony DiGiorgio: is, for those that don't know, is not a common neurosurgical procedure. ⁓ done a grand total of zero since graduating residency.
Elad Levy: Yes, very rare.
Anish Koka: ⁓ man.
Elad Levy: But that's I sort of fell in love with neuroanatomy and neurosurgery.
Anish Koka: Amazing. from there, Pitt then ⁓ Buffalo under another esteemed gentleman. You trained under Dr. Hopkins, correct?
Elad Levy: I did and as I was going up to the fellowship, Dave Lunsford was a chair, it just switched over to Dave from Peter Janetta and he said when you go to Buffalo to learn endovascular, you're going to learn more from Nick Hopkins outside the endosuite than inside. Nick was very entrepreneurial and they were so right, watching him sort of navigate health systems and You know, he was really the father of thrombectomy. So people forget, prior to 2015, we had no intervention for strokes. If you had a stroke, you went to the hospital, you got medicine, and you hoped for the best. And in 2001, when I was a fellow, we had a patient come in with a stroke who didn't do well. And he looked at me he said, if cardiologists can stop heart attacks, we should be able to stop strokes. And fast forward. hundreds of papers later in 15 years and animal models and a lot of basic science and in 2015 us and several wonderful partners around the world published a New England Journal, A New Standard of Care of Thrombectomy. that was sort of... Again, second eye opening of what innovation looks like, paradigm shifts. The first one, if we go back, is actually Dartmouth. So the coach leaves my junior year or my sophomore year at Concept2 and reinvents what the oars look like. So if anybody knows seen rowing lately, they're not symmetric. They almost look like hatchets. That was created circa 1992 and revolutionized the sport. The physics of those oars that for hundred years were symmetric spoons, overnight changed this concept too. Again that was an epiphany how innovation overnight changed a sport that was centuries old. Go to Buffalo 2001 listening to Nick over 10 years, you 2015 papers get published in New England Journal. A whole new paradigm shift for a million Americans that potentially have a stroke.
Anish Koka: The thing I've always found so interesting as coming from the cardiology side of things, know, I mean, this all happened while I was in, you know, I mean, while I was in training, right. I terms of this revolution in, you know, mechanical thrombectomy and, ⁓ you know, Anthony some time talking about ⁓ this the last podcast. The thing ⁓ impressed me much was that this was neurosurgeons ⁓ that were the charge. You know, you are the ones that really took ownership of these stroke patients. you describe to me a little bit about, how, that, you know, how that happened for instance, endovascular, right? mean, surgeons for the longest time, ⁓ right. have, have poo pooed, ⁓ you ⁓ anything that isn't open, open surgical, right? I mean, they're like, ⁓ you know, so anything was endovascular, seemed to be little bit like that was, that was beneath the surgeon. How ⁓ neurosurgery really, you embrace that it's really neurosurgeons that have. have that have pushed that forward, know, not, not cardiologists, not folks that, you know, probably, probably, you know, I think part of the reason for that is of course, there's no cardiologist that wants to manage, you know, reperfusion injury in the brain in the norm intensive care unit, right? And it's like, okay, we need a surgeon because the brain is swelling. Now what do do? Right? I mean, I think that's partly what the barrier was for cardiologists that had the catheter skills, but yeah. Yeah.
Elad Levy: Nick actually was trying to embrace the cardiologist. We have a paper published, I was an author on it, Should Cardiologists Do Stroke? But it was a slow burn. So at first the neurosurgeons, you're right, they're like, this isn't surgery, this is radiology stuff or interventional cardiology stuff. And I love stories as you know, so I'll tell you another one. So it's 2005, 2006, I'm at a meeting, ASITN, which has been
Anish Koka: Yeah. Hahaha.
Elad Levy: renamed but it's a vascular meaning. I present the first case, you know, I'm a young attending, I'm four years out, I'm invited to give a podium talk at this meeting and I present the first case of putting stents, bifurcation stents in the middle cerebral artery for a young lady who had a stroke. So we're stenting these vessels open and this was the predicate to modern stroke devices. And she did great. We borrowed that technology actually from the cardiologist because they do bifurcation stents all the time. And I present this and a very famous chairman, and I won't name him now, but in a the Northeastern program stands up. chest is up. think he's going to just give me the biggest accolade of my young attending. I'm like, I've made it. And he says, Dr. Levy, if I had a tomato, I would throw it at your face. ⁓ pariah, ⁓ renegade and.
Anish Koka: Hahaha
Elad Levy: I wanted to, I went, mean, think of a roller coaster. I was at such a high until he said that now I'm like ground swallowing me up before tears start rolling down my face. So I come back to Nick Hopkins and I tell him what happened. I said, the world hates us. The neurosurgeons hate us. And he says, if you weren't eliciting a visceral response, you're probably not doing something that important. And I'm like, okay. So just stick with it. And then the slow burn eventually neurosurgeons.
Anish Koka: Hahaha
Elad Levy: Accepted this and eventually now the field has turned right 80 % of what we do in vascular is end of it is endovascular It's not open anymore
Anish Koka: Yeah. So you helped establish, so I mean, your story, the story is not just, know, the Doctors' Lounge Health Policy Podcast, the story is not just the ASC that is amazing, and we're going get to it for sure. But even before that, I mean, this whole story is awesome. You you talked about mechanical thrombectomy, ⁓ then ⁓ me about the command trial.
Elad Levy: So I'm a big, know, and if we talk about rowing, right, you're only as good as your last ERG test. do we really want to be sort of a one hit wonder? We did thrombectomy and that's it. So kind of what's next. And the question we asked is what happens to all those stroke patients that we couldn't help as much, right? They still have significant deficit. you know, so we start getting into a world of technology with brain computer interface and Tom Oxley and Synchron. We sort of approach, they approached us, we approached them. It's an endovascular brain computer interface, right? We can put this up through the veins it creates a digital motor. It records the motor cortex, creates a digital motor output. And I treated a quadriplegic basically stroke patient, a brainstem stroke patient, as well as ALS patients. And we're the Wright Brothers of aviation phase, right? That's where we are. But in the next five to 10 years, it's unimaginable. how we can restore lost humanity, lost function, patients that are disconnected from the world because they can't speak, they can't move. So imagine being able to outsource that to a digital voice, a digital wheelchair, digital smart home. amazing.
Anish Koka: What? And this is well before Neura Link. mean, Neura Link comes on much afterwards. Can you tell us a little bit about how your differences, distinctions? Are you working with Elon right now?
Elad Levy: We're hoping to, so we're definitely having conversations. And the beautiful thing about Neuralink is it's poised to be in an outpatient center. This robotically driven, minimal incision, minimally invasive, perfect for the outpatient center. ⁓ We have the only outpatient neurosurgery center. So we're in conversation with people on his team. We're working with other BCIs. Precision is one of them. just got back from Europe. We're looking at another technology called CoreTech. So there are many, many brain computer interfaces out there. I don't know if any of them is perfect yet. But certainly, think as these coalesce or as maybe they're mergers, we're going to get there. But we're in the right brother's phase right now. We're not yet into, you know, Mach 1, Mach 2 or Mach 3.
Anish Koka: Yeah, Musk is of course incredibly ⁓ and tells a good story. certainly sitting ⁓ seems the stuff he's talking about, ⁓ it does seem ⁓ pretty ⁓ far the So I wonder if we'll ⁓ do what he's in terms of having He's talked about quadriplegics walking again and stuff and he's like, yeah, well, it's just a physics problem. I'm like, well, hold on there. That's true.
Elad Levy: Well, I wouldn't bet against him, right? Elon is a brilliant person who changed the world multiple times over. Yeah, ⁓ one thing he said that was really interesting and we should think about is that a human standing next to a tree is like an iPhone next to a human and what he calls processing speed. ⁓ we have technology. So I'm in the let's restore humanity camp. There are going to be questions of.
Anish Koka: Right. Yeah. Alright.
Elad Levy: can we create super humans, right? So there's already that discussion and the neuroethics around that another time.
Anish Koka: Absolutely, absolutely. You I would love to get something implanted so that I could have your ERG time, whatever your ridiculous 2K time was. Like, yeah, put that in my lats. All right. So I know. now, ⁓ the Ambulatory neurosurgery center, a neurosurgical center, the only one that exists. Anthony, sure have a bunch of questions ⁓ here. So let you ⁓ start off and then have a bunch of questions. Yeah.
Elad Levy: Hahaha. There you go.
Anthony DiGiorgio: I just want to be able to keep up with my kids. Well, was, you I'm thinking mentioning, you know, putting basically doing functional neurosurgery in an outpatient setting, endovascular techniques, carotid stenting. ⁓ I much of this is traditionally done in the hospital because the payment model we have steers patients there versus how much actually has a ⁓ clinical need to be done in a hospital setting versus this ambulatory surgery setting. And really what's, know, for our audience that that's not too familiar with the two modes, what's really the difference between You know, your ASC and the hospital down the street.
Elad Levy: I'm going to unpack that sort of layer by layer. But I'm to start with 10 years ago for everyone out here, knees, hips, all done in the hospital. 15 years ago, imaging, MRIs done in a hospital, right? That's all now outpatient. Why? Easier for the patient, lower cost of care, lower turnovers. So angiograms, right? What is an angiogram? We put a catheter in a vessel, we shoot the vessels of the head and neck. And those patients go home that day in a hospital. Why do they have to go to a So these patients go home the same day. And then the other question is sometimes they come into the hospital and there is an open heart that needs to be done, ⁓ dissection, liver surgery, trauma, brain bleed. And then these patients get bumped or canceled. What is the cost to the health care system? What is the cost to that patient, right? They just took a day off from work and the family. So what if we just said all these healthy patients, they're going home the same day. just do them outpatient. They're never going to get canceled. We've published literature, 10 to 15 minute turnover times. So we're doing several of these, of the time of a hospital turnover. And then we did a survey. All the respondents, we had about 70 % response rate, five out of five. I challenge any hospital to get 100%, five out of five ratings. And then we asked the question, OK, if we can do angiograms, can we do aneurysms? So we said, let's be scientific. So we looked at a series that I published of 2,000 of my own treated brain aneurysms. And it had a complication rate of about 3 and 1 percent all comers. And we said, what subset of this had almost a zero complication rate? And we said these are patients that get flow diversion or stents in a certain location, paraclinoid aneurysm, certain location. So let's start with those, the healthiest patients, the most straightforward anatomy. And then we published, because I think it's very important to peer review literature as physicians, Evidence-based medicine. We said we'll do a small cohort of 10. And they all went home the same day. And now that's our standard. We've done about 50 aneurysms, which are straightforward, healthy patients. Of course, you still need a hospital for patients with comorbidities. But when the anatomy is straightforward and the patient's relatively healthy, do it in the hospital. Or do it in the outpatient center. And what's our cost of care, our reimbursement? Same as 90 % of the hospital. How did we do that? I think that's the question. So go ahead.
Anthony DiGiorgio: So what, I mean, I was going to get down to that point about the cost, right? So you, you mentioned, and I think people sort of gloss over this fact that things are cheaper in the ASC. Why? Why is, why are things cheaper in the ASC? What, when you take that patient from the hospital and you go to your physician controlled ASC, what enables you to have lower costs than the hospital down the street? What is it specifically about physicians being in control and your center that can actually drive down that cost?
Elad Levy: Love that question. So first I'll say with device costs, we pay a much lower device implant cost than the hospital does. So let's start with that. So we negotiate that as physicians. think physicians are much more effective at negotiating with vendors than hospital administrators. And we've proven that. Second, I'll ask both of you, how many hospital employees do you think it takes to get a person from check-in into a procedure or OR room? and then all the way back to recovery. How many do you think?
Anthony DiGiorgio: From my experience, it's gotta be no less than 10,000.
Elad Levy: Yeah, it's usually somewhere between 15 to 20 so a person checks them in then you have a transport team Then you have a nurse intake another transport team to holding holding team or our team cleaning team Transport so I'll tell you all that work is done by the same four people So once the person goes walks themselves into the holding area the same nurse that does the intake Will then wheel the patient?
Anish Koka: No. ⁓
Elad Levy: to the OR or the patient will walk into the procedure lab. There'll be about four healthcare workers and physicians plus the physicians. When the procedure is done, we bifurcate, we divide and conquer. Two, we'll take the patient back to recovery and two, we'll do a room cleaning. We don't have a cleaning team during the day. Of course, at night there's a deep cleaning with custodial engineers. So the work of four or five people displaces 20 or 15 turnover you pay for that hour 15 minutes and then here's the model right we don't pay we don't say you have to be here eight hours we're gonna pay you eight hours we say we're gonna pay you for your day but when you're done you're done so if you finish in three hours you're still paid for 10 hours and so we flip that model which creates unbelievable efficiency because if who doesn't want to work for three or four hours and get paid for 10 hours Right?
Anish Koka: So you mentioned that's fantastic. And by the way, like this is the biggest, mean, we got to clip that for why is it that physician-owned hospitals, you know, would work so much better than, you know, these corporate, know, mega monsters that are essentially are just welfare programs. mean, they're welfare. It's It's just, it's so, angers me so much to see the level of insufficiency. I mean, listen to what he just said. I mean, ⁓ what Dr. just said, ⁓ you know, have, I mean, think about all the different people are like, ⁓ this is the transport team. is this. And actually, we just said, well, you know, he can, the patient can walk themselves into the area where instead of having a transport team that does something, right? So, I mean, it's, it's fantastic. part about ⁓ reimbursement, right? mean, if costs are significantly lower, reimbursement, what, what, ideal world, what should reimbursement be in ASCs?
Elad Levy: Yeah. Ideally, I'd love it to be site neutral, right? Ideally. So what you pay in the hospital, should pay the ASC. But this is what we said. is why literature matters. So we provided the payers with literature showing safety of conscious sedation. Here are my complication rates for these patients. And you would think there was resistance. But the payers ⁓ it all. We want to drive this all because we know there's no cancellation. There's no delay. There's high satisfaction, no infection rates. They get it. And I think they think five to 10 years from now when this is more ubiquitous, they can then probably start driving down rates. But right now we're getting the same rates, 90 % of hospital. So they're getting a 10 % savings. Patient is getting an unbelievable experience with no fear of being delayed or canceled. The physicians are happy, right? This is quintuple aim. Care of the patient. care of the health care team, population health, access to everybody, right, lowering the cost curve.
Anish Koka: Right. And this is a beautiful thing. The savings are captured by the owners of the owners that made this an efficient thing. And we should completely embrace that. you're doing something at a very high quality at lower cost, then yeah, go to town. Is there a... What's your... protocol, you must have some protocols to decide who can't be done at an ASC, I assume. Like, how do you go through that and how do you decide that?
Elad Levy: Absolutely. So there is sort of inclusion and exclusion. So when I look at a carotid stent or an aneurysm or stenting for pseudo tumor, whatever, exclusion criteria will include ejection fraction less than 30, somebody who's on home oxygen or severe COPD, poor renal status. So we go through a list of comorbidities and that's why you need strong hospital partners. Or we'll look at the anatomy and I'm like that is treacherous anatomy that that's going to require a lot of acrobatics and we don't feel comfortable doing it at the outpatient center. This is the bottom line I tell the partners so just ask yourself this one question if this is your mother this patient are you doing it at the outpatient center you're doing at the hospital as long as you kind of use that litmus we're going to be okay right we're going to come to the right conclusion almost all the time.
Anthony DiGiorgio: So you mentioned a policy that, sort of drives some of the inequities that we see with physician ownership versus these large hospital systems, which was the lack of site neutrality. So Medicare patient, gets done in the hospital. They get paid the hospital outpatient department rate. get their procedure done at the ASC. They get paid the ASC rate, which sometimes is substantially less than, ⁓ than the hospital outpatient rate. The other policy, ⁓ that we didn't touch on yet that I think is worth mentioning is the inpatient only list, right? So there are certain procedures that Medicare just won't let you do in an ASC, even if you've proven that it's safe, they have this list of procedures that are inpatient only. And so even if you show ample data that it's safe and cheaper, Medicare still won't let you do that. So how much do those two policies sort of drive where these patients are done beyond just the patient safety?
Elad Levy: So all the Medicare patients are being done in the hospital because everything we do is an IPO. It's inpatient. All the angiograms right now, though I think that's going to change if you saw some CMS data, but all the angiograms, all the interventions, everything we do endovascularly is all inpatient. So we can't do Medicare. party payers, private payers certainly are very eager.
Anish Koka: Hmm.
Elad Levy: And their patients are asking, so we have patients coming in now asking, do I have to be done in the hospital? I heard you do these at the outpatient center. Can we be done? We have patients who are, do a telehealth visit who will fly in just to be done under conscious sedation or at the outpatient center. And then usually we'll keep them in town overnight and then they'll fly out the next morning.
Anish Koka: Now there's no negotiating with Medicare in terms of what their ASC rate is, right? So, so Medicare, you, they did allow it, if they, know, the inpatient only this kind of went away and they did allow certain procedures in the ASC, they would just set a rate and you would then do those procedures. Will that cut into your, I mean, would that be a problem for you? Because of course you're, you're busy enough with commercial volume and now you're going to take ⁓ a cut. And if you want to do Medicare patients at, at, ⁓ at, at your ASC.
Elad Levy: We would, we would take a pay cut, at the end of the day, always, you know, we have to be governed by like, just do the right thing. And I know it's tried or cliche, but you know, if you're doing the right thing, good things happen. And that's kind of was my, you know, when I took over for Nick and that was Nick's, you know, when he built this program with those family values, I promised him I would never forget it. So I'm to take this opportunity in the podcast to say like that, that's our governor. try to do the right thing even when it's hard. So if we're doing Medicare there, great. And we do. Some of the spine that we do there is approved by Medicare and some of the guys do Medicare spine there.
Anish Koka: Yeah, I mean, and this is the thing that needs to get out there more in terms of ethics ⁓ practicing the financial ethics. mean, ethics in general, but this idea physicians are not governed a similar way to how ⁓ MBAs are governed. mean, if anything, ⁓ have, you something that butts up against us just going after patients, for instance, right? you own a practice, when you're the physician who's actually seeing patients and touching patients and the one that's ⁓ to them when they come back, it is extremely hard to, I even if you wanted to, ⁓ even your ethics allowed you your personal ethics said, no, no, this is a business and I'm going to send them to collections and ⁓ send people them. I mean, that just it just just hits much, much differently. And then you're describing it and you're saying, OK, you know, even if even if we're going to take a pay cut with Medicare at the ASE, we're just going to we've got to do what's right. We can't not do that because, know, because we're just going to take a pay cut.
Elad Levy: Yeah, I think people don't realize that you're not going into medicine because it's not really financially as lucrative as people think, right? There are much easier ways. My brother runs a hedge fund, and I will tell you, much easier ways to do well than having a brother who runs a hedge fund. So this is nice, and neurosurgery and certainly other disciplines in medicine, it's a calling, right? We're people, people. We want to care for people. Certainly, we want to be compensated for the work we do. We don't want to be abused and taken advantage of. But that's reciprocal, right? We have a relationship with these patients. We're going to offer the best care we can and the best venue we can. That's it.
Anthony DiGiorgio: Yeah, I even more than, I mean, I totally agree with the ethics point, but the same time, if word gets out that you're going after patients with collections, ⁓ referrals are probably going to dry up too, right? So there is a market mechanism to, you know, kind of tamp down on some of that ⁓ unethical behavior as well.
Anish Koka: Excellent.
Elad Levy: Right.
Anish Koka: That's a point. right. ⁓ the AAC stuff, ⁓ Do you think, I guess to round that out before going on to another topic, have kind of a unique model because you came from a hospital-backed kind of Is that, do you your is ⁓ ⁓ elsewhere?
Elad Levy: For an ANSC, and I love that term, Ametrine Neurosurgery Center, to succeed, you need sort of a spine and pain engine, right? That's an engine. To call yourself an ANSC, you'll need the vascular, that's a value proposition, you can do BCI, angiograms, maybe you partner with a peripheral interventionist, we have, so he uses the endosuite to do peripheral stuff, and then the functional and gamma knife. Yeah, think to have a full, it is a unique model, it is reproducible, but you have to be able to pivot. So I was giving grand rounds at an academic shop in Northwestern, right, at Chicago. And was at your shop about a year ago. If you have a strong hospital partner, there are many ways to do this. Maybe you this as a joint venture. Maybe you say to the hospital, If you build this, you share some of the profit margin back with the department so we can buy the microscopes or the head frames or some of the other capital equipment to keep us current. There many ways of revenue sharing and partnership. You don't have to be independent. We were independent because at the time the hospital didn't share the vision. So we sort of the green light.
Anish Koka: Do you, sorry, go ahead to finish up, sorry.
Elad Levy: No, I was going to say, and just for the people listening, we were profitable six months after opening the door. Can I give a secret tip? Here. Have your contracts negotiated before you open the door. Because once you open the door,
Anish Koka: Of
Anthony DiGiorgio: Please.
Elad Levy: Now your expense accounts rolling, right? You're paying. And payers will know that. And then it's sort of they have leverage. So contracts done and signed before you are spending $1 with your door open. And it's amazing how many ASCs appreciate that little, probably obvious, but maybe not so obvious point.
Anthony DiGiorgio: I think you're the third physician entrepreneur that specifically has made that point. So point taken.
Anish Koka: Would you be interested in running the hospital? So tomorrow somebody comes to you and say, Dr. Levy, you've done such an amazing job. Come run this hospital.
Anthony DiGiorgio: It's like you read my mind there, Anish.
Anish Koka: Sorry, sorry.
Elad Levy: I don't know. I don't know. don't know. That's a tough job. That's a tough job with a lot of headaches and union and boy, I think ⁓ now I'm happy kind of growing this ANSC and hoping that nationally this sort of catches on and happy to share kind of tips, tricks, secrets and ⁓ that it scales.
Anthony DiGiorgio: Well, let's maybe take that, take that a different direction tomorrow. Dr. Oz RFK wake up and say physician on hospitals. we're going to allow them ⁓ flip switch. would you interested in growing into a hospital? What would it take to take Atlas from ASC to a hospital? And is that feasible?
Anish Koka: Yes.
Elad Levy: That is by the time we finish this call. ⁓ running a physician-owned hospital all day every day. So when we built this, we built it modular. And I'll say land in Buffalo is certainly not as much cheaper than land in San Francisco or in parts California. So there is land space to grow more ORs, potentially more angiosuits, maybe more ⁓ care space. if this would be If we can't have physician-owned hospitals with more than 24-hour stays, we would add on to that in a heartbeat.
Anthony DiGiorgio: What do you think? mean, physical infrastructure wise, know, Medicare has this two to two rule. if our listeners aren't familiar with it, you have to have, I think an average of two patients staying two nights, to be considered a hospital versus an ASC is really like, there's no, there's no one thing that, makes an ASC into a hospital aside from this kind of arbitrary, CMS rule. what, infrastructure wise, more ORs, ⁓ a more beds, ⁓ bigger staffing.
Elad Levy: So we have about 20 recovery bays. So we have recovery bays, but yeah, you'd have to have 24 hour staffing. That's probably the biggest infrastructure change that we would do. So the staffing ends around four o'clock. Our last procedures end somewhere around three o'clock and everyone goes home. So if we're make this a hospital, then the infrastructure is 24 overnight nursing, overnight care.
Anthony DiGiorgio: Let's just double, go back to that point. Everyone goes home at four o'clock. think that's worth, that is worth highlighting right there. I mean, that's a lot of academic centers, that's your second case start time, it's four o'clock.
Elad Levy: Everyone does that before class.
Anish Koka: Ha ha ha.
Elad Levy: You know, my first case is 7 a.m. start, which means 7 a.m. on the table and 10-minute turnovers, we usually finish a good amount of cases by then.
Anthony DiGiorgio: And that's, I mean, you're increasing access to care, right? So if you are at an inefficient, I mean, we talk about inefficiencies as if the physician is just annoyed by the fact that turnover is long. You get to treat more patients because you have better turnover and that means more patients get the care they need. ⁓ so this is also, you know, if you have a herniated disc and you can't walk because your pain is so bad, you want a place that has a quick turnover because that just means you can get treated sooner. So this isn't just a. know, physicians are annoyed by long turnover. This is actually a patient access to care issue.
Elad Levy: Oh, that is a great point. I was speaking to my spine colleague the other day. He was finished at 2 p.m. I think he did two ACDFs and two lumbar fusions, kind of staggering, you know, appropriately, finished by 2, 2.30. In the hospital, that would be midnight, right? So imagine a 90-minute turnover three times, right? That's four and a half hours of just turnover time added onto your day.
Anthony DiGiorgio: Yeah, exactly.
Elad Levy: That's a lot of minutes that you're sacrificing in your life. That's a commodity. can spend it, but you can't buy it.
Anish Koka: You know, this is, mean, this is what Dr. Giorgio, you know, has less hair than you. And I can understand why. I mean, he's literally, he's pulling his hair out in between these turnover at times.
Elad Levy: because he doesn't have an A in that scene.
Anthony DiGiorgio: Exactly. Right, again, I'm seeing a patient in clinic and I can, maybe me, let's not talk about my institution, but ⁓ if a is seeing a patient in clinic and they they can only get two cases done in a day, then that just backs up the wait list. And so now that patient can only get their surgery in ⁓ two months instead two weeks because you just can't get the volume of cases done with the equivalent amount calendar days.
Elad Levy: And that's an argument we made to the healthcare system and I think you're the physicians listening to your podcast need to make to their healthcare system. When you're booking three, four, five months out because of your block time for bottleneck and you can only do two cases a day, imagine just decompressing that bottleneck and now you're only booking four weeks out or six weeks out. So patients don't have to wait four months to get their spine fixed or their brain tumor out if it's not emergent their aneurysm fixed.
Anish Koka: Well, hope folks pay attention to the fact that you're talking about being able to do this outside the of the hospital ⁓ industrial that exists. really, policy should that there's a massive amount of regulations that makes it an absolute headache to go into hospitals right now to try to change things. someone, we hope in future ⁓ generation that somebody will empower to take a buzzsaw to the regulations that kind of tie ⁓ up ⁓ hospitals and make things so inefficient and make things so expensive ⁓ thereby, functionally restricting access care in that frame. ⁓ All right, so, ⁓
Elad Levy: The other one last one, we talked about clinical care, but innovation and entrepreneur. So how much time does it take to get an IRB approval or clinical trial in healthcare systems, typically in a university setting or a major hospital setting? Eight months, 12 months, not talking about your centers, but that's kind of the average when I go around the country. In the ANSC, it takes two to four weeks because we're using kind of a third party IRB and the physicians are deciding what technologies we want to do a clinical trial in and the companies want to do it there because there's no overhead. You're not paying for all the layers of management through large hospital systems and university systems. So by the time the major systems can start enrolling, we've been enrolled for eight months. What does that mean for the patients? That means faster to market, lower cost to market. So we're bringing better technology to patient care in a way that major centers can't. and that's becoming a nidus. So all these companies now are calling and saying, hey, for these neurosurgical implants that are for migraine or bladder control, neurogenic bladder, little things that don't need to be in a hospital, NeuroLink potentially, let's do these in an outpatient center.
Anish Koka: That's it.
Anthony DiGiorgio: Gosh.
Anish Koka: It's a fantastic point, fantastic point about just pace of change and the of the stickiness again of the hospital systems and the kind of the infrastructure that kind of bogs things down there. But so that's all great. I can't let the two of you go. mean, we have two august neurosurgeons, Dr. DiGiorgio, of course, UCSF neurosurgery and of course, Dr. Levy, chairman at his program, without talking a little bit about the neurosurgical
Anthony DiGiorgio: It really is.
Anish Koka: issues, ⁓ residencies, etc. I mean, you we've talked, we've talked a lot about that. That's been in the news a lot. ⁓ know, ⁓ know you've actually, Dr. Levy, been somewhat of champion ⁓ of internationally trained ⁓ I getting right? Getting US board certification. What is that driven the fact that there's just a massive demand, massive ⁓ demand, not enough supply? What are your, you know, What's your general thoughts about how we should do this?
Elad Levy: So, great question. when I was a director of the American Board of Neurological Surgery, we tried to create what's called the alternative pathway. somebody ⁓ in another country and now they're working in a university hospital and they're training our residents and they're truly luminaries and they're publishing and they're doing studies. They should be eligible for a pathway to become board certified because patients feel comfortable when they're like, doctor, are you board certified? There's a layer of protection when you're board certified. And if we're trusting them to train our future generations, maybe they should be board certified. So hoping to create that pathway for sort of a select group highly trained people committed to education. That's kind of what I did on the board. But you're right, there are manpower issues. are pockets in the United States, especially for stroke, where there's no stroke doctrine so we talk sometimes cardiologists can they train up and that didn't really take stickiness to use your word. robotics going to answer that ⁓ do we just need to increase the workforce ⁓ the is that we continue to coalesce highly trained subspecialists in populous and desirable areas. ⁓ San Boston, New York City, right.
Anish Koka: Yeah. ⁓
Anthony DiGiorgio: Buffalo.
Elad Levy: Not so much buffalo.
Anthony DiGiorgio: Well, but I mean, I think I think that there's something to be offered there. You know, if it would it's a much different value proposition to somebody to go have an ownership stake in an ASC, be able to have the autonomy that comes with entrepreneurship and being at the head of the health care team instead of being an employee, you know, at ⁓ nice part the country for a significant pay cut and ⁓ loss of So I think, you know, this is point we keep kind of harping on in this podcast is that physician ownership really does help the rural healthcare population. mean, Buffalo, I said this with some snark, but you know, Buffalo is this now center for innovation. And who would have thought that Buffalo, New York would be this, right? Nothing against the town, but you know, it's not San Francisco, San Diego, New York, you know, so it's, I think there is something to be said about physician ownership really helping to alleviate the the problems we have in rural healthcare.
Elad Levy: Yeah, think, you know, Buffalo is known as the city of good neighbors. And I think that really describes the people, the people live here were hearty people that can deal with 10 months of winter and two weeks of summer. we some of the highest physician satisfaction ratings, right? We all just did the survey. I forget what surveys out of all I think out of all the departments. And certainly ⁓ when look at neurosurgery across the country or satisfaction ratings were almost five out of five throughout. I give a lot of credit to the ANSC. People, know, our young spine colleagues are not starting cases at 9 p.m. on a Friday. He's actually watching a Disney movie with his daughter at 9 p.m. on a Friday now. So he's happy and I can retain him.
Anish Koka: Ha ha ha. I know about this whole Buffalo happy thing. mean, if you, you you've asked the Buffalo football fans, they all give a five, they all give a five out of five, even though they've lost all these Super Bowls, they're like jumping off of things naked on the, I mean, I don't even know what's going on there. It's the water in Buffalo. So I don't know. I mean, I, I'm pretty sure the nurse serves in Buffalo would be happy with or without the NSC.
Elad Levy: Yeah, we're not having... Yeah, that's right. No, we have hope. Josh is going to do it this year. We have hope.
Anthony DiGiorgio: Bye.
Anish Koka: But let me let me push both of you on this. Okay, I do want to push you guys on this. Look, there is of course if we could have a Dr. Levi, Dr. DiGiorgio at every every five miles across the massive United States, that would be amazing. But you know, there's a problem here, right? I mean, they're just the volume to train what you guys do. Look, I'm a I'm a general cardiologist. mean, it's not hard. It's not that it's not it's much easier training general cardiologists than to train somebody who's efficient at doing mechanical thrombectomy at 3am. Correct? mean, There are certain number of cases that have to go around. is the solution? Because will say, you know, this is the larger meta, in the context of the larger issue that I'm talking about, some will say, okay, well, we can't do that here ⁓ in efficient manner. There's enough cases, takes too long to train a neurosurgeon here, blah, blah, blah. Or we need to import folks abroad to do this. You know, most of the folks that are going to be imported from abroad are going to come from, you know, places that have pretty large supply demand. mean, they're producing lots and lots of physicians. So India, Pakistan, produce a massive number of physicians. Right. And and most Indian Pakistani physicians would love to come here and train the system, be and be underneath you guys and become nurses. Do you what?
Elad Levy: Yeah.
Anish Koka: that, do you see problems with that or what the issue? ⁓ What do see with that or do you think that's a good idea?
Elad Levy: Certainly it's complex. I've trained people from all over the world. I've trained fellows from Asia, Middle East, Europe. Right now we have a resident from Columbia, a person redoing his residency, who trained in India. My father was a foreign medical graduate. He trained in Italy and I think he was fantastic surgeon in OBGYN. But you cannot regulate what comes in. So while there are certainly some fantastic technicians and physicians who will train overseas at very reputable programs, how can you decipher the exceptional ones from the ones that probably wouldn't have the same merit or wouldn't have the same skill set or knowledge base as American trained? So when you have an American trained physician, right? It's a curriculum, they're boarded, they're the standard. You know what you're getting. The concern is, When you have people coming in from overseas, it becomes very difficult to know what the product is. It may be phenomenal, or not.
Anthony DiGiorgio: Yeah, I think you're going to have exceptions in both directions. You're certainly going to have some American trained, know, Christopher Dunsch, Dr. Death type, but thankfully those are the exception, not the rule. and you're going to have some brilliance international people. ⁓ think it's a good point. How do you vet, in any sort of way? I think the ABNS does a really good job. I think that the board process that we have with the case auditing, a submission of cake, consecutive case lists, so can't really hide cases.
Anish Koka: Anthony, any comments?
Anthony DiGiorgio: I think so to your point about an alternate pathway for foreign medical graduates to go through that and have their cases audited, I think it is one way hopefully to have some sort of public trust in I think board certification is a way I would almost like it to have a little more teeth and more continual auditing if you can be done in a way that's easier to cases and data collection, all that without ⁓ putting an burden on the person submitting for boards. Um, but I think that's one way, uh, you know, having an independent society review cases and make sure, cause you really just, want to make sure people are safe. Not everyone's going to be a Dr. Levy and be, you know, top of their game, uh, uh, varsity rower and, know, type a everything you just want, you want people that are safe, right? Not dangerous.
Elad Levy: Right, that's exactly right. That's purpose of board certification. Are you a safe doctor? That's what the public deserves.
Anthony DiGiorgio: Exactly.
Anish Koka: Excellent. All right. Well, Dr. Levy, you know, we've taken up a lot of your time. really can't thank you enough for on. mean, your story is ⁓ We didn't even get to the fact that you're for Grey's Anatomy.
Elad Levy: seasons two through four. other writer Shonda Rhimes was a Dartmouth grad and a lot of Dartmouth grads I think were physician consultants in the early years. That is correct.
Anthony DiGiorgio: Ha
Anish Koka: So you, so McSteamy or McDreamy, which one were you kind of modeled? know, was modeled after you or was it McDreamy? Which one? That's ⁓ ⁓
Elad Levy: Maybe your listeners can decide that, huh? But did you notice that the Patrick Dempsey character eventually was sculling, right? He was rowing at some point.
Anthony DiGiorgio: Hahaha
Anish Koka: ⁓ yeah, it was you. All right, we got it. We got our answer. We got our answer. ⁓ Outstanding. Levy, it's just an absolute pleasure to have you. mean, so we will hopefully have you back at point to enlighten us again with ⁓ something that ⁓ you've but thanks again for coming on. ⁓ All righty. so much.
Anthony DiGiorgio: Co incidence I think not.
Elad Levy: This was so much fun guys. This was great. Thank you for having me.
Anthony DiGiorgio: Thank you.
Elad Levy: Well, first, thanks for having me. And I think that's a great question. I'll tell you, if I may, a little story. So when I became chair, we had nine attendings here in Buffalo. We grew the department to over 20. And when you try to cram 20 neurosurgeons into the space that was barely adequate for nine, you're going to have bottlenecks. So we have young attendings with young families starting elective cases at 9 PM on a Friday, or on a Saturday, or on a Sunday. So when I became chair, we had nine attendings here in Buffalo. ⁓ We grew the department to over 20. ⁓ And when you try to cram 20 neurosurgeons into the space that was adequate for nine, you're going to have So we have young attendings with young families ⁓ starting elective cases at 9 PM on a Friday, or on a Saturday, or on a Sunday. with hour plus turnovers, not sustainable. Not sustainable for more volume, not sustainable to meeting budget. So we came to the hospital and we said, hey, there's many things we do we can move outpatient. So we know in the spine world, lumbar laminectomy, anterior cervical discectomy, some other spine, but we can move angiograms outside. They go home the same day. And potentially some functional neurosurgery. And decompress a hospital, give more block time. with hour plus turnovers, not sustainable. Not sustainable for more volume, not sustainable to meeting budget. So we came to the hospital and we said, hey, there's many things we do we can move outpatient. So we know in the spine world, lumbar laminectomy, anterior cervical discectomy, some other spine, but we can move angiograms outside. They go home the same day. And potentially some functional neurosurgery. And decompress a hospital, give more block time. hospital wasn't interested. Follow-up question, do you want to do a joint venture? Will risk not interested? Final question, do you mind if we do this ourselves? And you would have thought I gave a Rodney Dangerfield monologue with the laughter. But they gave us permission, so we identified some land near one of our office buildings. And two and a half years later, we're doing 3,000 cases a year. hospital wasn't interested. Follow-up question, do you want to do a joint venture? Will risk not interested? Final question, do you mind if we do this ourselves? And you would have thought I gave a Rodney Dangerfield monologue with the laughter. But they gave us permission, so we identified some land near one of our office buildings. And two and a half years later, we're doing 3,000 cases a year. We have some of the highest physician satisfaction ratings of any department in the hospital and certainly higher than we've ever had as a department. We have some of the highest physician satisfaction ratings of any department in the hospital and certainly higher than we've ever had as a department.
Anthony DiGiorgio: I can, I can certainly relate to those, those start times and I don't know, an hour turnover is a, would be nice. Sometimes I wish it was that quick, but that's, I think that's, that's an incredible story. ⁓ go ahead. ⁓
Anish Koka: Wow. Did, did, so this was kind of in partnership with the hospital. Do they have ownership of, part ownership of the land or part ownership of the, does that ⁓ work? It sounds like ⁓ is not like an antagonistic thing. This is something that's ⁓ done together.
Elad Levy: So no, but we came from a very good place. So we have a phenomenal relationship with our hospital partners. Buffalo is a small community and rising tide raises all ships. And we want a strong hospital partner makes a strong neurosurgery department. So we approached the hospital and perhaps it wasn't the right time or maybe they had other commitments or another vision, but they gave us permission to do this ourselves. So there wasn't a hostility or ⁓ ⁓ antagonistic sentiment. We said if you don't want to do it, can we do this? we did this. And ⁓ after opened, we put in the first outpatient privately owned gamma knife. We had the busiest gamma knife unit in the United States. So Buffalo had one. They were doing ⁓ many, hundreds of cases, more than the sweet spot. Again, we approached the hospital partners and said, is there any interest in putting a second gamma knife unit in this town because of the volume that we've now built. No interest, so against all odds, we got cobalt and we put a gamma knife now. So we're doing radio surgery, intervention, diagnostics, functional neurosurgery, obviously spine, and some soon to be basic craniotomies.
Anish Koka: So to be clear, to elucidate, you are the chair of neurosurgery at SUNY Buffalo. ⁓ hold the Nelson Hopkins endowed chair, ⁓ ⁓ the hospital and you ⁓ ⁓ department of neurosurgery for the hospital. They have their own neurosurgical department.
Elad Levy: Yes. Yes. Yes. Correct, so just sort of expand. So the University at Buffalo, SUNY Buffalo, Jacob School of Medicine, we are the Department of Neurosurgery. I'm the chair of that department and we have about 21 or so neurosurgeons and some other ancillaries. The hospital system, Kaleida Health and other hospitals in town, are with the university but are two different entities. We are the predominant
Anish Koka: Yeah.
Elad Levy: service line for that hospital, right? That's where all the residents train. I'm the director of neuroscience for Collider Health. So two different hats. And then Atlas Neurosurgery Center is the same. We have the same physicians that are in the department, but under a separate LLC, a separate corporation, independent from the university, independent from the hospital system. That's very important.
Anish Koka: Okay. So you run the residency program for hospital. that ⁓ the university? Sorry, for the university. Yes.
Elad Levy: for the university. I guess, guess you're giving me dollars to throw through the hospital. So you're correct. So yeah, we are the department that trains the residents. We have three fellowships, endovascular functional spine, multiple fellowships in spine. train three residents a year. We train four or five endovascular fellows a year. So it's a, it's a busy shop and a little bit of a proud moment. I think in 2023 or 24, J &S published our volumes as one of the highest volume academic neurosurgery programs in the United States.
Anish Koka: Wow, that's incredible. was this, you used the we, when you were talking about wanting to do this and set up shop and stuff. How many of there were you and, or was it just you who kind of approached it? Can you speak a little bit about how that happened?
Elad Levy: So honestly, I think it was a collective sort of pain that we were having. We were having a lot of pain points. And by no fault, I certainly don't want to blame the system, the hospital system. It's just when you grow a department, Nick Hopkins built UB neurosurgery. And then when I became chair 12 years ago, we took it from nine to 21. So we need more room and space. So I think the collective pain points, many of the physicians said, if they're not going to do this, let's do it ourselves. And Doug Moreland, one of the partners, is the energy behind this. He's very entrepreneurial and really helped drive this. He sort of was the point person who made this happen for us.
Anish Koka: Before, going to get into some of the stuff, but thought we'd remiss not to talk a little bit about your personal journey to this point. Can you tell us a little bit about, ⁓ I understand father was an Obigine, is that right? You weren't born in the US, you were born in Israel, is that correct?
Elad Levy: That's right, I was born in Israel and spent some time in Italy while he was in medical school in Bologna. So he was a pro soccer player, not a good one. So that was a short career and he wanted to actually go to be a veterinarian. He wanted to go to a vet school, but his grades were so poor that in Italy it was too hard to get into vet school. So he went to med school. Eventually finished school and came, we moved to New Jersey and
Anish Koka: Ha ha!
Anthony DiGiorgio: Ha!
Elad Levy: not a lot of jobs there, he basically used his Italian to get construction jobs and eventually landed a residency, wanted to be an orthopedic surgeon, but landed a residency as an OBGYN. We moved to Northern New York, rural, rural New York, just south of the Canadian border. after a few years there ⁓ education, they sent me to a boarding school, Chote Rosemary Hall, I think. ⁓ sort of learned to row there and talk about this bloody hand. that was, you know, I pulled that oar like that was my lifeline. I this is my way into a better world. And eventually recruited to row at Dartmouth where I rode for four years and after that med school and then neurosurgery at Pitt.
Anish Koka: Wow, so you were a varsity college rower, my goodness.
Elad Levy: Yeah, I wrote for the US under 19 team in France at Junior Worlds and survived four years of Dartmouth rowing and had illusions or delusions of making it to the next level. that wasn't in my destiny.
Anish Koka: That is... ⁓ my god. Wow. I briefly get on the erg every now and then, so I'm already now... That is more impressive to me than anything you've done with this ASC or this chair of neurosurgery. When did the ergs start coming out? Did the ergs come out like in the last 20 years or so? I when you were rowing, did they have ergs or no?
Elad Levy: I'm They did. they had sort of early generation flywheels. I was a chote from 1987 to 1989. And I tell the story that I'd wake up at six in the morning and again, no one's driving this. I try to tell my kids this, but you got to want this. I'd wake up, run down the hill to the gym, wait for them to turn the lights on, row on this early generation flywheel that had a tachometer. Like, you know, it was like a bike wheel and you just see the tachometer turn. barely make it back in time for French class, which was my first period, fall asleep through French class, wasn't great. then get back to practice and try to get to practice at the end of the day. Larry who was a coach at Dartmouth, saw something in me and said, hey, you want to roll for us at Dartmouth? I'd love to.
Anish Koka: amazing, that's awesome. ⁓ trajectory then took you to ⁓ my hometown where I grew You did residency in, guess, neurosurgery residency there. Is that right?
Elad Levy: Yeah, so when I was at GW in DC, again, I wanted to go to med school work at Still Row, so I was trying to row 5 o'clock in the morning on the Potomac with Potomac Boat Club, and I'd walk into class still dripping wet and... My sneakers, I remember, were tied to my backpack and there'd be one seat in the middle and as I walked I'd hit, not on purpose, my sneakers would hit all the students in the head as I'm trying to go. I'd sit down and open a can of Bush's baked beans as I try to eat that for breakfast while I'm trying to listen to biochem shortly which after I'd fall asleep I tell my friends, don't let me fall asleep, I need to hear this lecture. Fell asleep.
Anish Koka: So Dr. Georgiou, this guy, Dr. Levy, he would be most likely to become a neurosurgeon, ⁓
Anthony DiGiorgio: Yeah, real underachiever like most of us.
Elad Levy: Yeah,
Anish Koka: enjoys enjoys pain to a significant degree. Yeah.
Elad Levy: So how do I get into neurosurgery? I applied for orthopedic summer fellowship. You know, they have those first year, second year summer fellowships. First choice orthopedics, second choice neurosurgery. Didn't get the ortho, got the neurosurgery. And Dr. Shaker at the time was a chairman, so skull-based tumors. am serious when I tell you for two years, I thought the most common neurosurgical procedure was a petroclival meningioma, followed only by redo petroclival meningiomas.
Anthony DiGiorgio: is, for those that don't know, is not a common neurosurgical procedure. ⁓ done a grand total of zero since graduating residency.
Elad Levy: Yes, very rare.
Anish Koka: ⁓ man.
Elad Levy: But that's I sort of fell in love with neuroanatomy and neurosurgery.
Anish Koka: Amazing. from there, Pitt then ⁓ Buffalo under another esteemed gentleman. You trained under Dr. Hopkins, correct?
Elad Levy: I did and as I was going up to the fellowship, Dave Lunsford was a chair, it just switched over to Dave from Peter Janetta and he said when you go to Buffalo to learn endovascular, you're going to learn more from Nick Hopkins outside the endosuite than inside. Nick was very entrepreneurial and they were so right, watching him sort of navigate health systems and You know, he was really the father of thrombectomy. So people forget, prior to 2015, we had no intervention for strokes. If you had a stroke, you went to the hospital, you got medicine, and you hoped for the best. And in 2001, when I was a fellow, we had a patient come in with a stroke who didn't do well. And he looked at me he said, if cardiologists can stop heart attacks, we should be able to stop strokes. And fast forward. hundreds of papers later in 15 years and animal models and a lot of basic science and in 2015 us and several wonderful partners around the world published a New England Journal, A New Standard of Care of Thrombectomy. that was sort of... Again, second eye opening of what innovation looks like, paradigm shifts. The first one, if we go back, is actually Dartmouth. So the coach leaves my junior year or my sophomore year at Concept2 and reinvents what the oars look like. So if anybody knows seen rowing lately, they're not symmetric. They almost look like hatchets. That was created circa 1992 and revolutionized the sport. The physics of those oars that for hundred years were symmetric spoons, overnight changed this concept too. Again that was an epiphany how innovation overnight changed a sport that was centuries old. Go to Buffalo 2001 listening to Nick over 10 years, you 2015 papers get published in New England Journal. A whole new paradigm shift for a million Americans that potentially have a stroke.
Anish Koka: The thing I've always found so interesting as coming from the cardiology side of things, know, I mean, this all happened while I was in, you know, I mean, while I was in training, right. I terms of this revolution in, you know, mechanical thrombectomy and, ⁓ you know, Anthony some time talking about ⁓ this the last podcast. The thing ⁓ impressed me much was that this was neurosurgeons ⁓ that were the charge. You know, you are the ones that really took ownership of these stroke patients. you describe to me a little bit about, how, that, you know, how that happened for instance, endovascular, right? mean, surgeons for the longest time, ⁓ right. have, have poo pooed, ⁓ you ⁓ anything that isn't open, open surgical, right? I mean, they're like, ⁓ you know, so anything was endovascular, seemed to be little bit like that was, that was beneath the surgeon. How ⁓ neurosurgery really, you embrace that it's really neurosurgeons that have. have that have pushed that forward, know, not, not cardiologists, not folks that, you know, probably, probably, you know, I think part of the reason for that is of course, there's no cardiologist that wants to manage, you know, reperfusion injury in the brain in the norm intensive care unit, right? And it's like, okay, we need a surgeon because the brain is swelling. Now what do do? Right? I mean, I think that's partly what the barrier was for cardiologists that had the catheter skills, but yeah. Yeah.
Elad Levy: Nick actually was trying to embrace the cardiologist. We have a paper published, I was an author on it, Should Cardiologists Do Stroke? But it was a slow burn. So at first the neurosurgeons, you're right, they're like, this isn't surgery, this is radiology stuff or interventional cardiology stuff. And I love stories as you know, so I'll tell you another one. So it's 2005, 2006, I'm at a meeting, ASITN, which has been
Anish Koka: Yeah. Hahaha.
Elad Levy: renamed but it's a vascular meaning. I present the first case, you know, I'm a young attending, I'm four years out, I'm invited to give a podium talk at this meeting and I present the first case of putting stents, bifurcation stents in the middle cerebral artery for a young lady who had a stroke. So we're stenting these vessels open and this was the predicate to modern stroke devices. And she did great. We borrowed that technology actually from the cardiologist because they do bifurcation stents all the time. And I present this and a very famous chairman, and I won't name him now, but in a the Northeastern program stands up. chest is up. think he's going to just give me the biggest accolade of my young attending. I'm like, I've made it. And he says, Dr. Levy, if I had a tomato, I would throw it at your face. ⁓ pariah, ⁓ renegade and.
Anish Koka: Hahaha
Elad Levy: I wanted to, I went, mean, think of a roller coaster. I was at such a high until he said that now I'm like ground swallowing me up before tears start rolling down my face. So I come back to Nick Hopkins and I tell him what happened. I said, the world hates us. The neurosurgeons hate us. And he says, if you weren't eliciting a visceral response, you're probably not doing something that important. And I'm like, okay. So just stick with it. And then the slow burn eventually neurosurgeons.
Anish Koka: Hahaha
Elad Levy: Accepted this and eventually now the field has turned right 80 % of what we do in vascular is end of it is endovascular It's not open anymore
Anish Koka: Yeah. So you helped establish, so I mean, your story, the story is not just, know, the Doctors' Lounge Health Policy Podcast, the story is not just the ASC that is amazing, and we're going get to it for sure. But even before that, I mean, this whole story is awesome. You you talked about mechanical thrombectomy, ⁓ then ⁓ me about the command trial.
Elad Levy: So I'm a big, know, and if we talk about rowing, right, you're only as good as your last ERG test. do we really want to be sort of a one hit wonder? We did thrombectomy and that's it. So kind of what's next. And the question we asked is what happens to all those stroke patients that we couldn't help as much, right? They still have significant deficit. you know, so we start getting into a world of technology with brain computer interface and Tom Oxley and Synchron. We sort of approach, they approached us, we approached them. It's an endovascular brain computer interface, right? We can put this up through the veins it creates a digital motor. It records the motor cortex, creates a digital motor output. And I treated a quadriplegic basically stroke patient, a brainstem stroke patient, as well as ALS patients. And we're the Wright Brothers of aviation phase, right? That's where we are. But in the next five to 10 years, it's unimaginable. how we can restore lost humanity, lost function, patients that are disconnected from the world because they can't speak, they can't move. So imagine being able to outsource that to a digital voice, a digital wheelchair, digital smart home. amazing.
Anish Koka: What? And this is well before Neura Link. mean, Neura Link comes on much afterwards. Can you tell us a little bit about how your differences, distinctions? Are you working with Elon right now?
Elad Levy: We're hoping to, so we're definitely having conversations. And the beautiful thing about Neuralink is it's poised to be in an outpatient center. This robotically driven, minimal incision, minimally invasive, perfect for the outpatient center. ⁓ We have the only outpatient neurosurgery center. So we're in conversation with people on his team. We're working with other BCIs. Precision is one of them. just got back from Europe. We're looking at another technology called CoreTech. So there are many, many brain computer interfaces out there. I don't know if any of them is perfect yet. But certainly, think as these coalesce or as maybe they're mergers, we're going to get there. But we're in the right brother's phase right now. We're not yet into, you know, Mach 1, Mach 2 or Mach 3.
Anish Koka: Yeah, Musk is of course incredibly ⁓ and tells a good story. certainly sitting ⁓ seems the stuff he's talking about, ⁓ it does seem ⁓ pretty ⁓ far the So I wonder if we'll ⁓ do what he's in terms of having He's talked about quadriplegics walking again and stuff and he's like, yeah, well, it's just a physics problem. I'm like, well, hold on there. That's true.
Elad Levy: Well, I wouldn't bet against him, right? Elon is a brilliant person who changed the world multiple times over. Yeah, ⁓ one thing he said that was really interesting and we should think about is that a human standing next to a tree is like an iPhone next to a human and what he calls processing speed. ⁓ we have technology. So I'm in the let's restore humanity camp. There are going to be questions of.
Anish Koka: Right. Yeah. Alright.
Elad Levy: can we create super humans, right? So there's already that discussion and the neuroethics around that another time.
Anish Koka: Absolutely, absolutely. You I would love to get something implanted so that I could have your ERG time, whatever your ridiculous 2K time was. Like, yeah, put that in my lats. All right. So I know. now, ⁓ the Ambulatory neurosurgery center, a neurosurgical center, the only one that exists. Anthony, sure have a bunch of questions ⁓ here. So let you ⁓ start off and then have a bunch of questions. Yeah.
Elad Levy: Hahaha. There you go.
Anthony DiGiorgio: I just want to be able to keep up with my kids. Well, was, you I'm thinking mentioning, you know, putting basically doing functional neurosurgery in an outpatient setting, endovascular techniques, carotid stenting. ⁓ I much of this is traditionally done in the hospital because the payment model we have steers patients there versus how much actually has a ⁓ clinical need to be done in a hospital setting versus this ambulatory surgery setting. And really what's, know, for our audience that that's not too familiar with the two modes, what's really the difference between You know, your ASC and the hospital down the street.
Elad Levy: I'm going to unpack that sort of layer by layer. But I'm to start with 10 years ago for everyone out here, knees, hips, all done in the hospital. 15 years ago, imaging, MRIs done in a hospital, right? That's all now outpatient. Why? Easier for the patient, lower cost of care, lower turnovers. So angiograms, right? What is an angiogram? We put a catheter in a vessel, we shoot the vessels of the head and neck. And those patients go home that day in a hospital. Why do they have to go to a So these patients go home the same day. And then the other question is sometimes they come into the hospital and there is an open heart that needs to be done, ⁓ dissection, liver surgery, trauma, brain bleed. And then these patients get bumped or canceled. What is the cost to the health care system? What is the cost to that patient, right? They just took a day off from work and the family. So what if we just said all these healthy patients, they're going home the same day. just do them outpatient. They're never going to get canceled. We've published literature, 10 to 15 minute turnover times. So we're doing several of these, of the time of a hospital turnover. And then we did a survey. All the respondents, we had about 70 % response rate, five out of five. I challenge any hospital to get 100%, five out of five ratings. And then we asked the question, OK, if we can do angiograms, can we do aneurysms? So we said, let's be scientific. So we looked at a series that I published of 2,000 of my own treated brain aneurysms. And it had a complication rate of about 3 and 1 percent all comers. And we said, what subset of this had almost a zero complication rate? And we said these are patients that get flow diversion or stents in a certain location, paraclinoid aneurysm, certain location. So let's start with those, the healthiest patients, the most straightforward anatomy. And then we published, because I think it's very important to peer review literature as physicians, Evidence-based medicine. We said we'll do a small cohort of 10. And they all went home the same day. And now that's our standard. We've done about 50 aneurysms, which are straightforward, healthy patients. Of course, you still need a hospital for patients with comorbidities. But when the anatomy is straightforward and the patient's relatively healthy, do it in the hospital. Or do it in the outpatient center. And what's our cost of care, our reimbursement? Same as 90 % of the hospital. How did we do that? I think that's the question. So go ahead.
Anthony DiGiorgio: So what, I mean, I was going to get down to that point about the cost, right? So you, you mentioned, and I think people sort of gloss over this fact that things are cheaper in the ASC. Why? Why is, why are things cheaper in the ASC? What, when you take that patient from the hospital and you go to your physician controlled ASC, what enables you to have lower costs than the hospital down the street? What is it specifically about physicians being in control and your center that can actually drive down that cost?
Elad Levy: Love that question. So first I'll say with device costs, we pay a much lower device implant cost than the hospital does. So let's start with that. So we negotiate that as physicians. think physicians are much more effective at negotiating with vendors than hospital administrators. And we've proven that. Second, I'll ask both of you, how many hospital employees do you think it takes to get a person from check-in into a procedure or OR room? and then all the way back to recovery. How many do you think?
Anthony DiGiorgio: From my experience, it's gotta be no less than 10,000.
Elad Levy: Yeah, it's usually somewhere between 15 to 20 so a person checks them in then you have a transport team Then you have a nurse intake another transport team to holding holding team or our team cleaning team Transport so I'll tell you all that work is done by the same four people So once the person goes walks themselves into the holding area the same nurse that does the intake Will then wheel the patient?
Anish Koka: No. ⁓
Elad Levy: to the OR or the patient will walk into the procedure lab. There'll be about four healthcare workers and physicians plus the physicians. When the procedure is done, we bifurcate, we divide and conquer. Two, we'll take the patient back to recovery and two, we'll do a room cleaning. We don't have a cleaning team during the day. Of course, at night there's a deep cleaning with custodial engineers. So the work of four or five people displaces 20 or 15 turnover you pay for that hour 15 minutes and then here's the model right we don't pay we don't say you have to be here eight hours we're gonna pay you eight hours we say we're gonna pay you for your day but when you're done you're done so if you finish in three hours you're still paid for 10 hours and so we flip that model which creates unbelievable efficiency because if who doesn't want to work for three or four hours and get paid for 10 hours Right?
Anish Koka: So you mentioned that's fantastic. And by the way, like this is the biggest, mean, we got to clip that for why is it that physician-owned hospitals, you know, would work so much better than, you know, these corporate, know, mega monsters that are essentially are just welfare programs. mean, they're welfare. It's It's just, it's so, angers me so much to see the level of insufficiency. I mean, listen to what he just said. I mean, ⁓ what Dr. just said, ⁓ you know, have, I mean, think about all the different people are like, ⁓ this is the transport team. is this. And actually, we just said, well, you know, he can, the patient can walk themselves into the area where instead of having a transport team that does something, right? So, I mean, it's, it's fantastic. part about ⁓ reimbursement, right? mean, if costs are significantly lower, reimbursement, what, what, ideal world, what should reimbursement be in ASCs?
Elad Levy: Yeah. Ideally, I'd love it to be site neutral, right? Ideally. So what you pay in the hospital, should pay the ASC. But this is what we said. is why literature matters. So we provided the payers with literature showing safety of conscious sedation. Here are my complication rates for these patients. And you would think there was resistance. But the payers ⁓ it all. We want to drive this all because we know there's no cancellation. There's no delay. There's high satisfaction, no infection rates. They get it. And I think they think five to 10 years from now when this is more ubiquitous, they can then probably start driving down rates. But right now we're getting the same rates, 90 % of hospital. So they're getting a 10 % savings. Patient is getting an unbelievable experience with no fear of being delayed or canceled. The physicians are happy, right? This is quintuple aim. Care of the patient. care of the health care team, population health, access to everybody, right, lowering the cost curve.
Anish Koka: Right. And this is a beautiful thing. The savings are captured by the owners of the owners that made this an efficient thing. And we should completely embrace that. you're doing something at a very high quality at lower cost, then yeah, go to town. Is there a... What's your... protocol, you must have some protocols to decide who can't be done at an ASC, I assume. Like, how do you go through that and how do you decide that?
Elad Levy: Absolutely. So there is sort of inclusion and exclusion. So when I look at a carotid stent or an aneurysm or stenting for pseudo tumor, whatever, exclusion criteria will include ejection fraction less than 30, somebody who's on home oxygen or severe COPD, poor renal status. So we go through a list of comorbidities and that's why you need strong hospital partners. Or we'll look at the anatomy and I'm like that is treacherous anatomy that that's going to require a lot of acrobatics and we don't feel comfortable doing it at the outpatient center. This is the bottom line I tell the partners so just ask yourself this one question if this is your mother this patient are you doing it at the outpatient center you're doing at the hospital as long as you kind of use that litmus we're going to be okay right we're going to come to the right conclusion almost all the time.
Anthony DiGiorgio: So you mentioned a policy that, sort of drives some of the inequities that we see with physician ownership versus these large hospital systems, which was the lack of site neutrality. So Medicare patient, gets done in the hospital. They get paid the hospital outpatient department rate. get their procedure done at the ASC. They get paid the ASC rate, which sometimes is substantially less than, ⁓ than the hospital outpatient rate. The other policy, ⁓ that we didn't touch on yet that I think is worth mentioning is the inpatient only list, right? So there are certain procedures that Medicare just won't let you do in an ASC, even if you've proven that it's safe, they have this list of procedures that are inpatient only. And so even if you show ample data that it's safe and cheaper, Medicare still won't let you do that. So how much do those two policies sort of drive where these patients are done beyond just the patient safety?
Elad Levy: So all the Medicare patients are being done in the hospital because everything we do is an IPO. It's inpatient. All the angiograms right now, though I think that's going to change if you saw some CMS data, but all the angiograms, all the interventions, everything we do endovascularly is all inpatient. So we can't do Medicare. party payers, private payers certainly are very eager.
Anish Koka: Hmm.
Elad Levy: And their patients are asking, so we have patients coming in now asking, do I have to be done in the hospital? I heard you do these at the outpatient center. Can we be done? We have patients who are, do a telehealth visit who will fly in just to be done under conscious sedation or at the outpatient center. And then usually we'll keep them in town overnight and then they'll fly out the next morning.
Anish Koka: Now there's no negotiating with Medicare in terms of what their ASC rate is, right? So, so Medicare, you, they did allow it, if they, know, the inpatient only this kind of went away and they did allow certain procedures in the ASC, they would just set a rate and you would then do those procedures. Will that cut into your, I mean, would that be a problem for you? Because of course you're, you're busy enough with commercial volume and now you're going to take ⁓ a cut. And if you want to do Medicare patients at, at, ⁓ at, at your ASC.
Elad Levy: We would, we would take a pay cut, at the end of the day, always, you know, we have to be governed by like, just do the right thing. And I know it's tried or cliche, but you know, if you're doing the right thing, good things happen. And that's kind of was my, you know, when I took over for Nick and that was Nick's, you know, when he built this program with those family values, I promised him I would never forget it. So I'm to take this opportunity in the podcast to say like that, that's our governor. try to do the right thing even when it's hard. So if we're doing Medicare there, great. And we do. Some of the spine that we do there is approved by Medicare and some of the guys do Medicare spine there.
Anish Koka: Yeah, I mean, and this is the thing that needs to get out there more in terms of ethics ⁓ practicing the financial ethics. mean, ethics in general, but this idea physicians are not governed a similar way to how ⁓ MBAs are governed. mean, if anything, ⁓ have, you something that butts up against us just going after patients, for instance, right? you own a practice, when you're the physician who's actually seeing patients and touching patients and the one that's ⁓ to them when they come back, it is extremely hard to, I even if you wanted to, ⁓ even your ethics allowed you your personal ethics said, no, no, this is a business and I'm going to send them to collections and ⁓ send people them. I mean, that just it just just hits much, much differently. And then you're describing it and you're saying, OK, you know, even if even if we're going to take a pay cut with Medicare at the ASE, we're just going to we've got to do what's right. We can't not do that because, know, because we're just going to take a pay cut.
Elad Levy: Yeah, I think people don't realize that you're not going into medicine because it's not really financially as lucrative as people think, right? There are much easier ways. My brother runs a hedge fund, and I will tell you, much easier ways to do well than having a brother who runs a hedge fund. So this is nice, and neurosurgery and certainly other disciplines in medicine, it's a calling, right? We're people, people. We want to care for people. Certainly, we want to be compensated for the work we do. We don't want to be abused and taken advantage of. But that's reciprocal, right? We have a relationship with these patients. We're going to offer the best care we can and the best venue we can. That's it.
Anthony DiGiorgio: Yeah, I even more than, I mean, I totally agree with the ethics point, but the same time, if word gets out that you're going after patients with collections, ⁓ referrals are probably going to dry up too, right? So there is a market mechanism to, you know, kind of tamp down on some of that ⁓ unethical behavior as well.
Anish Koka: Excellent.
Elad Levy: Right.
Anish Koka: That's a point. right. ⁓ the AAC stuff, ⁓ Do you think, I guess to round that out before going on to another topic, have kind of a unique model because you came from a hospital-backed kind of Is that, do you your is ⁓ ⁓ elsewhere?
Elad Levy: For an ANSC, and I love that term, Ametrine Neurosurgery Center, to succeed, you need sort of a spine and pain engine, right? That's an engine. To call yourself an ANSC, you'll need the vascular, that's a value proposition, you can do BCI, angiograms, maybe you partner with a peripheral interventionist, we have, so he uses the endosuite to do peripheral stuff, and then the functional and gamma knife. Yeah, think to have a full, it is a unique model, it is reproducible, but you have to be able to pivot. So I was giving grand rounds at an academic shop in Northwestern, right, at Chicago. And was at your shop about a year ago. If you have a strong hospital partner, there are many ways to do this. Maybe you this as a joint venture. Maybe you say to the hospital, If you build this, you share some of the profit margin back with the department so we can buy the microscopes or the head frames or some of the other capital equipment to keep us current. There many ways of revenue sharing and partnership. You don't have to be independent. We were independent because at the time the hospital didn't share the vision. So we sort of the green light.
Anish Koka: Do you, sorry, go ahead to finish up, sorry.
Elad Levy: No, I was going to say, and just for the people listening, we were profitable six months after opening the door. Can I give a secret tip? Here. Have your contracts negotiated before you open the door. Because once you open the door,
Anish Koka: Of
Anthony DiGiorgio: Please.
Elad Levy: Now your expense accounts rolling, right? You're paying. And payers will know that. And then it's sort of they have leverage. So contracts done and signed before you are spending $1 with your door open. And it's amazing how many ASCs appreciate that little, probably obvious, but maybe not so obvious point.
Anthony DiGiorgio: I think you're the third physician entrepreneur that specifically has made that point. So point taken.
Anish Koka: Would you be interested in running the hospital? So tomorrow somebody comes to you and say, Dr. Levy, you've done such an amazing job. Come run this hospital.
Anthony DiGiorgio: It's like you read my mind there, Anish.
Anish Koka: Sorry, sorry.
Elad Levy: I don't know. I don't know. don't know. That's a tough job. That's a tough job with a lot of headaches and union and boy, I think ⁓ now I'm happy kind of growing this ANSC and hoping that nationally this sort of catches on and happy to share kind of tips, tricks, secrets and ⁓ that it scales.
Anthony DiGiorgio: Well, let's maybe take that, take that a different direction tomorrow. Dr. Oz RFK wake up and say physician on hospitals. we're going to allow them ⁓ flip switch. would you interested in growing into a hospital? What would it take to take Atlas from ASC to a hospital? And is that feasible?
Anish Koka: Yes.
Elad Levy: That is by the time we finish this call. ⁓ running a physician-owned hospital all day every day. So when we built this, we built it modular. And I'll say land in Buffalo is certainly not as much cheaper than land in San Francisco or in parts California. So there is land space to grow more ORs, potentially more angiosuits, maybe more ⁓ care space. if this would be If we can't have physician-owned hospitals with more than 24-hour stays, we would add on to that in a heartbeat.
Anthony DiGiorgio: What do you think? mean, physical infrastructure wise, know, Medicare has this two to two rule. if our listeners aren't familiar with it, you have to have, I think an average of two patients staying two nights, to be considered a hospital versus an ASC is really like, there's no, there's no one thing that, makes an ASC into a hospital aside from this kind of arbitrary, CMS rule. what, infrastructure wise, more ORs, ⁓ a more beds, ⁓ bigger staffing.
Elad Levy: So we have about 20 recovery bays. So we have recovery bays, but yeah, you'd have to have 24 hour staffing. That's probably the biggest infrastructure change that we would do. So the staffing ends around four o'clock. Our last procedures end somewhere around three o'clock and everyone goes home. So if we're make this a hospital, then the infrastructure is 24 overnight nursing, overnight care.
Anthony DiGiorgio: Let's just double, go back to that point. Everyone goes home at four o'clock. think that's worth, that is worth highlighting right there. I mean, that's a lot of academic centers, that's your second case start time, it's four o'clock.
Elad Levy: Everyone does that before class.
Anish Koka: Ha ha ha.
Elad Levy: You know, my first case is 7 a.m. start, which means 7 a.m. on the table and 10-minute turnovers, we usually finish a good amount of cases by then.
Anthony DiGiorgio: And that's, I mean, you're increasing access to care, right? So if you are at an inefficient, I mean, we talk about inefficiencies as if the physician is just annoyed by the fact that turnover is long. You get to treat more patients because you have better turnover and that means more patients get the care they need. ⁓ so this is also, you know, if you have a herniated disc and you can't walk because your pain is so bad, you want a place that has a quick turnover because that just means you can get treated sooner. So this isn't just a. know, physicians are annoyed by long turnover. This is actually a patient access to care issue.
Elad Levy: Oh, that is a great point. I was speaking to my spine colleague the other day. He was finished at 2 p.m. I think he did two ACDFs and two lumbar fusions, kind of staggering, you know, appropriately, finished by 2, 2.30. In the hospital, that would be midnight, right? So imagine a 90-minute turnover three times, right? That's four and a half hours of just turnover time added onto your day.
Anthony DiGiorgio: Yeah, exactly.
Elad Levy: That's a lot of minutes that you're sacrificing in your life. That's a commodity. can spend it, but you can't buy it.
Anish Koka: You know, this is, mean, this is what Dr. Giorgio, you know, has less hair than you. And I can understand why. I mean, he's literally, he's pulling his hair out in between these turnover at times.
Elad Levy: because he doesn't have an A in that scene.
Anthony DiGiorgio: Exactly. Right, again, I'm seeing a patient in clinic and I can, maybe me, let's not talk about my institution, but ⁓ if a is seeing a patient in clinic and they they can only get two cases done in a day, then that just backs up the wait list. And so now that patient can only get their surgery in ⁓ two months instead two weeks because you just can't get the volume of cases done with the equivalent amount calendar days.
Elad Levy: And that's an argument we made to the healthcare system and I think you're the physicians listening to your podcast need to make to their healthcare system. When you're booking three, four, five months out because of your block time for bottleneck and you can only do two cases a day, imagine just decompressing that bottleneck and now you're only booking four weeks out or six weeks out. So patients don't have to wait four months to get their spine fixed or their brain tumor out if it's not emergent their aneurysm fixed.
Anish Koka: Well, hope folks pay attention to the fact that you're talking about being able to do this outside the of the hospital ⁓ industrial that exists. really, policy should that there's a massive amount of regulations that makes it an absolute headache to go into hospitals right now to try to change things. someone, we hope in future ⁓ generation that somebody will empower to take a buzzsaw to the regulations that kind of tie ⁓ up ⁓ hospitals and make things so inefficient and make things so expensive ⁓ thereby, functionally restricting access care in that frame. ⁓ All right, so, ⁓
Elad Levy: The other one last one, we talked about clinical care, but innovation and entrepreneur. So how much time does it take to get an IRB approval or clinical trial in healthcare systems, typically in a university setting or a major hospital setting? Eight months, 12 months, not talking about your centers, but that's kind of the average when I go around the country. In the ANSC, it takes two to four weeks because we're using kind of a third party IRB and the physicians are deciding what technologies we want to do a clinical trial in and the companies want to do it there because there's no overhead. You're not paying for all the layers of management through large hospital systems and university systems. So by the time the major systems can start enrolling, we've been enrolled for eight months. What does that mean for the patients? That means faster to market, lower cost to market. So we're bringing better technology to patient care in a way that major centers can't. and that's becoming a nidus. So all these companies now are calling and saying, hey, for these neurosurgical implants that are for migraine or bladder control, neurogenic bladder, little things that don't need to be in a hospital, NeuroLink potentially, let's do these in an outpatient center.
Anish Koka: That's it.
Anthony DiGiorgio: Gosh.
Anish Koka: It's a fantastic point, fantastic point about just pace of change and the of the stickiness again of the hospital systems and the kind of the infrastructure that kind of bogs things down there. But so that's all great. I can't let the two of you go. mean, we have two august neurosurgeons, Dr. DiGiorgio, of course, UCSF neurosurgery and of course, Dr. Levy, chairman at his program, without talking a little bit about the neurosurgical
Anthony DiGiorgio: It really is.
Anish Koka: issues, ⁓ residencies, etc. I mean, you we've talked, we've talked a lot about that. That's been in the news a lot. ⁓ know, ⁓ know you've actually, Dr. Levy, been somewhat of champion ⁓ of internationally trained ⁓ I getting right? Getting US board certification. What is that driven the fact that there's just a massive demand, massive ⁓ demand, not enough supply? What are your, you know, What's your general thoughts about how we should do this?
Elad Levy: So, great question. when I was a director of the American Board of Neurological Surgery, we tried to create what's called the alternative pathway. somebody ⁓ in another country and now they're working in a university hospital and they're training our residents and they're truly luminaries and they're publishing and they're doing studies. They should be eligible for a pathway to become board certified because patients feel comfortable when they're like, doctor, are you board certified? There's a layer of protection when you're board certified. And if we're trusting them to train our future generations, maybe they should be board certified. So hoping to create that pathway for sort of a select group highly trained people committed to education. That's kind of what I did on the board. But you're right, there are manpower issues. are pockets in the United States, especially for stroke, where there's no stroke doctrine so we talk sometimes cardiologists can they train up and that didn't really take stickiness to use your word. robotics going to answer that ⁓ do we just need to increase the workforce ⁓ the is that we continue to coalesce highly trained subspecialists in populous and desirable areas. ⁓ San Boston, New York City, right.
Anish Koka: Yeah. ⁓
Anthony DiGiorgio: Buffalo.
Elad Levy: Not so much buffalo.
Anthony DiGiorgio: Well, but I mean, I think I think that there's something to be offered there. You know, if it would it's a much different value proposition to somebody to go have an ownership stake in an ASC, be able to have the autonomy that comes with entrepreneurship and being at the head of the health care team instead of being an employee, you know, at ⁓ nice part the country for a significant pay cut and ⁓ loss of So I think, you know, this is point we keep kind of harping on in this podcast is that physician ownership really does help the rural healthcare population. mean, Buffalo, I said this with some snark, but you know, Buffalo is this now center for innovation. And who would have thought that Buffalo, New York would be this, right? Nothing against the town, but you know, it's not San Francisco, San Diego, New York, you know, so it's, I think there is something to be said about physician ownership really helping to alleviate the the problems we have in rural healthcare.
Elad Levy: Yeah, think, you know, Buffalo is known as the city of good neighbors. And I think that really describes the people, the people live here were hearty people that can deal with 10 months of winter and two weeks of summer. we some of the highest physician satisfaction ratings, right? We all just did the survey. I forget what surveys out of all I think out of all the departments. And certainly ⁓ when look at neurosurgery across the country or satisfaction ratings were almost five out of five throughout. I give a lot of credit to the ANSC. People, know, our young spine colleagues are not starting cases at 9 p.m. on a Friday. He's actually watching a Disney movie with his daughter at 9 p.m. on a Friday now. So he's happy and I can retain him.
Anish Koka: Ha ha ha. I know about this whole Buffalo happy thing. mean, if you, you you've asked the Buffalo football fans, they all give a five, they all give a five out of five, even though they've lost all these Super Bowls, they're like jumping off of things naked on the, I mean, I don't even know what's going on there. It's the water in Buffalo. So I don't know. I mean, I, I'm pretty sure the nurse serves in Buffalo would be happy with or without the NSC.
Elad Levy: Yeah, we're not having... Yeah, that's right. No, we have hope. Josh is going to do it this year. We have hope.
Anthony DiGiorgio: Bye.
Anish Koka: But let me let me push both of you on this. Okay, I do want to push you guys on this. Look, there is of course if we could have a Dr. Levi, Dr. DiGiorgio at every every five miles across the massive United States, that would be amazing. But you know, there's a problem here, right? I mean, they're just the volume to train what you guys do. Look, I'm a I'm a general cardiologist. mean, it's not hard. It's not that it's not it's much easier training general cardiologists than to train somebody who's efficient at doing mechanical thrombectomy at 3am. Correct? mean, There are certain number of cases that have to go around. is the solution? Because will say, you know, this is the larger meta, in the context of the larger issue that I'm talking about, some will say, okay, well, we can't do that here ⁓ in efficient manner. There's enough cases, takes too long to train a neurosurgeon here, blah, blah, blah. Or we need to import folks abroad to do this. You know, most of the folks that are going to be imported from abroad are going to come from, you know, places that have pretty large supply demand. mean, they're producing lots and lots of physicians. So India, Pakistan, produce a massive number of physicians. Right. And and most Indian Pakistani physicians would love to come here and train the system, be and be underneath you guys and become nurses. Do you what?
Elad Levy: Yeah.
Anish Koka: that, do you see problems with that or what the issue? ⁓ What do see with that or do you think that's a good idea?
Elad Levy: Certainly it's complex. I've trained people from all over the world. I've trained fellows from Asia, Middle East, Europe. Right now we have a resident from Columbia, a person redoing his residency, who trained in India. My father was a foreign medical graduate. He trained in Italy and I think he was fantastic surgeon in OBGYN. But you cannot regulate what comes in. So while there are certainly some fantastic technicians and physicians who will train overseas at very reputable programs, how can you decipher the exceptional ones from the ones that probably wouldn't have the same merit or wouldn't have the same skill set or knowledge base as American trained? So when you have an American trained physician, right? It's a curriculum, they're boarded, they're the standard. You know what you're getting. The concern is, When you have people coming in from overseas, it becomes very difficult to know what the product is. It may be phenomenal, or not.
Anthony DiGiorgio: Yeah, I think you're going to have exceptions in both directions. You're certainly going to have some American trained, know, Christopher Dunsch, Dr. Death type, but thankfully those are the exception, not the rule. and you're going to have some brilliance international people. ⁓ think it's a good point. How do you vet, in any sort of way? I think the ABNS does a really good job. I think that the board process that we have with the case auditing, a submission of cake, consecutive case lists, so can't really hide cases.
Anish Koka: Anthony, any comments?
Anthony DiGiorgio: I think so to your point about an alternate pathway for foreign medical graduates to go through that and have their cases audited, I think it is one way hopefully to have some sort of public trust in I think board certification is a way I would almost like it to have a little more teeth and more continual auditing if you can be done in a way that's easier to cases and data collection, all that without ⁓ putting an burden on the person submitting for boards. Um, but I think that's one way, uh, you know, having an independent society review cases and make sure, cause you really just, want to make sure people are safe. Not everyone's going to be a Dr. Levy and be, you know, top of their game, uh, uh, varsity rower and, know, type a everything you just want, you want people that are safe, right? Not dangerous.
Elad Levy: Right, that's exactly right. That's purpose of board certification. Are you a safe doctor? That's what the public deserves.
Anthony DiGiorgio: Exactly.
Anish Koka: Excellent. All right. Well, Dr. Levy, you know, we've taken up a lot of your time. really can't thank you enough for on. mean, your story is ⁓ We didn't even get to the fact that you're for Grey's Anatomy.
Elad Levy: seasons two through four. other writer Shonda Rhimes was a Dartmouth grad and a lot of Dartmouth grads I think were physician consultants in the early years. That is correct.
Anthony DiGiorgio: Ha
Anish Koka: So you, so McSteamy or McDreamy, which one were you kind of modeled? know, was modeled after you or was it McDreamy? Which one? That's ⁓ ⁓
Elad Levy: Maybe your listeners can decide that, huh? But did you notice that the Patrick Dempsey character eventually was sculling, right? He was rowing at some point.
Anthony DiGiorgio: Hahaha
Anish Koka: ⁓ yeah, it was you. All right, we got it. We got our answer. We got our answer. ⁓ Outstanding. Levy, it's just an absolute pleasure to have you. mean, so we will hopefully have you back at point to enlighten us again with ⁓ something that ⁓ you've but thanks again for coming on. ⁓ All righty. so much.
Anthony DiGiorgio: Co incidence I think not.
Elad Levy: This was so much fun guys. This was great. Thank you for having me.
Anthony DiGiorgio: Thank you.