Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Market Forces Reshaping Orthopaedic Care with David Jevsevar, MD
The healthcare landscape is transforming at lightning speed, with consolidation reshaping how orthopaedic care is delivered across America. In this eye-opening conversation, Dr. David Jevsevar, CEO of OrthoVirginia, shares his unique perspective gained from navigating nearly every side of this complex equation—from private practice founder to hospital executive to leader of one of the nation's premier orthopaedic mega groups.
Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for the podcast series. Joining us today is Dr David Jevsevar.
Speaker 2:Dr Jevsevar attended St Vincent College for his undergraduate education and got his medical degree from Georgetown University School of Medicine. He completed his general surgery internship at the Mercy Hospital of Pittsburgh and then a research fellowship at MIT, followed by his orthopedic surgery residency at the Tufts affiliated orthopedic residency and Allegheny General Hospital. Dr Jez Savar also has his Master of Business Administration from Auburn University. He served in the Air Force and got out after serving as a major in the Air Force and then started a successful private practice which he subsequently sold to Intermountain Healthcare and became the director of their orthopedic clinical program. He then became the chair at Dartmouth Hitchcock for many years as an orthopedic surgeon there and then after that became the chief executive officer of OrthoVirginia. So, dr Jessavar, welcome to the podcast series, sir.
Speaker 3:Doug, thanks for having me. It's great to talk to you.
Speaker 2:You and I have had a somewhat similar career. I would say that your career has been absolutely outstanding. You've had quite a bit of achievement and done some really cool things. Really appreciate all your service to the country and the other things that you've done for our profession. And today we're going to talk about the effective market consolidation which you spoke at about at the AOA meeting last year.
Speaker 3:I think it's an important and critical topic, and one that I think most of us, as orthopedic surgeons, don't recognize its importance in our current healthcare ecosystem.
Speaker 2:Can you just overall tell us what your thoughts about? What is market consolidation and why should we care about it?
Speaker 3:Well, in the old world, when you and I started and you could start a practice and you could be easily a group of three or four surgeons, the system really didn't make that much of a difference.
Speaker 3:And this all happened around the turn of the century and with some well-meaning legislation like the ACA. But all of the legislation actually accelerated this concept of consolidation. The legislation actually accelerated this concept of consolidation. So first we started seeing consolidation amongst the payers and now, as we know, we're to four or five big healthcare insurance payers and you know they're making unbelievable profits and their consolidation have significant impact on the healthcare system.
Speaker 3:And so hospitals and health systems I think with the concern with the ACA about creating accountable care, organizations felt the need to consolidate to make sure that they had a large private practice base to ensure that they had patients coming to their facility. Once that occurred, then it became paramount that we had to drive the procedures that occur within hospitals and health care systems. So proceduralists and specialists like orthopedic surgeons and all of our subspecialties were obviously hired in droves by those organizations. I think, to counter that and to be competitive within the market, groups like Resurgence, which used to be part of, and OrthoVirginia, which I'm now part of, have felt the need to grow, to be able to maintain the mass and the heft to be able to compete within a robust musculoskeletal healthcare system.
Speaker 2:Yeah, there's a lot of that going on. There's a whole lot wrapped up in what you just talked about, and I cannot help but think that this has got to be a front burner issue for many orthopedic surgeons, and if they're not thinking about it, they should be thinking about it. So there's some terms I like to unwrap here. Can you tell us, like, what's the difference between vertical integration, hospital integration, non-traditional integration? How does that all work together?
Speaker 3:Sure. So I think Kaiser is in our world. Kaiser is probably the best example of a vertically integrated system. Intermountain Healthcare, which I used to work for, is another example of a vertically integrated health system. So in a vertically integrated system the system has basically every component of what we consider healthcare. So that includes the payer. So Kaiser has its own insurance plan. Intermountain has its own insurance plan. That includes the facility, so hospitals, ambulatory settings, imaging, all the rest, all the ancillary types of things that are out there. And then it also includes the clinicians, of which we, as orthopedic surgeons, are one of them. So that's an example of a vertically integrated health system. It can include home health. It can include in those systems. It does include everything.
Speaker 3:Horizontally integrated systems tend to be a little bit different and the best examples there are the big hospital systems. Maybe Advocate essentially would be one example of a horizontally integrated health system where they continue to scoop up hospitals. So they continue to kind of stay in their lane with the hospital and healthcare setting, maybe clinicians as well, but they don't go through the whole payer aspect of things at least not now, and they stay out of some areas of business. So they tend to consolidate in areas where they already have strength.
Speaker 2:Okay, how about non-traditional?
Speaker 3:Non-traditional integration, the types of things that we see with CVS or Amazon or other folks who traditionally are not in the healthcare space but are suddenly becoming players within the healthcare space. So with CVS, it's the purchase of one medical and trying to scale up. Or Amazon's purchase of one medical, trying to scale up all of those types of entities. So it's non-traditional participants into the healthcare system but are also have significant ability to have scale because they have large amounts of cash to be able to purchase and integrate these systems.
Speaker 2:And you talked a little bit of why orthopedic surgeons are opting for consolidation. Can you get a little bit more into thatopedic surgeons are opting for consolidation. Can you get a little bit more into that? And then also the Affordable Care Act had some unforeseen consequences that kind of drove us toward that. Your thoughts.
Speaker 3:Exactly, I don't think. As I said, I don't think it was the intent of the Affordable Care Act and some of the legislation previous to that that you know. Mandated electronic health records also was an example that, forced because of the cost of implementing EHRs, also forced some greater consolidation across organizations. The ACA again had a similar impact because when the thought with the ACA is we would be moving largely towards accountable care organizations, again, hospitals and health systems really were concerned that they needed to have scale to be able to ensure that they could manage a large area of primarily primary care practices so that they could meet all the tenants that were part of the original ACA and accountable care organizations. Orthopedic practices felt the need, I think, to keep up with that. So orthopedic surgeons had one of a couple choices and some of those choices have changed a little bit with time.
Speaker 3:If you were in a smaller group and you were in a market that had a dominant hospital or healthcare systems, for many of our practice colleagues it was just easier to sell their practice or become part of the hospital or healthcare system.
Speaker 3:They didn't have the financial wherewithal to be able to do a lot of this on their own.
Speaker 3:For some others of us, we were able to consolidate groups and we were able to create what we would call now these larger mega groups, and for a group like ours, that's 170 physicians but there are groups out there that are even bigger, but I would say any group over the age of over the number of 50 is a mega group or a big group. And now private equity, as you know, has come into the space as well and it's also trying to consolidate and take what's a fragmented system still within, especially, orthopedic practices and consolidate amongst those. So that's what we're seeing occur in the market. If you look at the last census that the Academy did which was way back in 2018, basically it flipped over 10 years. So in 10 years it went from approximately 65 to 70% of orthopedic surgeons being in some form of private practice to now 60 to 70% of orthopedic surgeons being in some type of employee practice if you want to call private equity and employee practice as well.
Speaker 2:Okay, and to some degree I think we talked about PPACA, but to some degree also the push for MIPS and APM participation also kind of also drives smaller practices into consolidation, don't you think? I mean, how are y'all involved in that at OrthoVirginia?
Speaker 3:Absolutely it does, because you have to be able to consolidate and you have to be able to measure, and in the smaller practice you only have a couple options for being able to do that and most of the smaller practices can't afford to have a full-time quality person that's working through the standardization and measurement of the outcomes that are required for whether it's MIPS, a new MVP or whatever. When you get to be a scale of something like OrthoVirginia, we do have the ability to be able to manage those internally and we're able to hardwire a lot of that within our organization to make sure that we are meeting our quality goals and we are hitting the outcome points that we need to make sure that we're competitive and that we're not losing money within this space.
Speaker 2:So I can hear a lot of my old friends, current friends in private practice yelling and screaming the whole way into this. They know what, my friends? They don't want to give up their autonomy. They'd much rather go into a mega group like OrthoVirginia than they would. Just historically, they would tell me them them be hospital employed or something like that. But they do see these advantages that you've laid out. But there are also certain disadvantages. Right, there are, I think, the physicians themselves. I mean, we can get to the community a minute, but just the physicians themselves. What? What are some of the disadvantages?
Speaker 3:absolutely. I think, regardless of practice setting from when you and I started Doug to now, loss of autonomy is real. It's real even in a practice like OrthoVirginia. I think our physicians have more autonomy than most orthopedic surgeons that are out there today, because now we are larger and that puts all of the shareholders of OrthoVirginia at risk. So whereas when you may have been in a small practice, it was maybe just you at risk or maybe one or two other partners at risk, now we have potentially 170 partners at risk, so we have to manage that, and managing that means that there's some loss of autonomy with that. The other aspect of that is that physicians feel especially orthopedic surgeons that came from smaller practices feel displaced from decision-making that impacts them. So the other hard part with a large group like ours is how to make sure that our members feel that they're participating in what's happening within the organization and that their voice is being heard.
Speaker 3:Again I think they have proportionate to or relative to other aspects that are out there employee physicians or academic physicians. I think they have more opportunity to participate, more opportunity to be heard, but again, it's less than it was 20 years ago.
Speaker 2:What's the impact of consolidation on, say, innovation, research, things like that?
Speaker 3:Well, I think we all see it in the various aspects of what we do.
Speaker 3:If you're part of an academic health system and when I was at Dartmouth, dartmouth is a great place, but even over the years that I was there, the emphasis had to change to become a little bit more about productivity, and whenever that emphasis changed to productivity, that took away from other academic pursuits such as funding of research or how to always meet our academic mission to the highest level.
Speaker 3:I think that occurs within employed physicians that are not in academic systems as well. Maybe they were doing things innovatively in their practice or they were involved with research or industry-sponsored research, and many of them now have such stringent conflict of interest rules that they can't be involved in any of those types of initiatives. And one of the hallmarks of orthopedic surgery has been innovation. That has driven a lot of the research that we have. So those things have gone away quite a bit and again at a practice like OrthoVirginia we've introduced a robust research infrastructure, but again it costs money to do that and our shareholders pay for that at one level or another. So you know we at least want to break even doing our research, but that's not always an easy endeavor.
Speaker 2:Now, speaking of OrthoVirginia, Resurgence Mile Group, emerge, orthocarolina, rothman, places like that we have the orthopedic mega group right and uh, my friends at ortho forum, which I was a very proud member of when I was at resurgence, uh told me at the time, about a year ago or so, there were 12 independent orthopedic mega groups in the U S. There may be more now, certainly. I think a lot of these have been formed because of the pressures of consolidation. How do you see the benefits of the mega group or some of the detractors per se? Speaking fairly, you are CEO of one of them and I was president of one of them, but what do you think?
Speaker 3:I think that to be able to compete effectively, like you, I get to travel around the country, I get to meet lots of folks and there are markets. There are some markets that still have a number of really what I would call really small groups of people, that are still practices of four to six, but nationally, to be able to compete in the big picture, we're not supposed to talk about things like leverage, because that doesn't add value to the health care system. But for me to be able to leverage what's happening at OrthoVirginia with our payers or with hospitals and health systems, I need the size, I need the breadth, I need the depth of everything that we do and everything that we have to be able to compete effectively within our market because our competitors have that. So I think all of the practices that are out there see that and they've grown to meet what they need to meet within the market to be able to maintain competition, to be able to provide the good services and excellent patient care that they would like to provide.
Speaker 3:I think one of the things that the mega groups are pretty good with is making sure that we're meeting our patient needs. We're meeting our patient needs. For us it's really, really important, because we may not have the brand names of some other academic institutions across the country or in some hospitals or healthcare systems that may have deeper pockets. So I do think that we try to provide patient experiences that are superior. I do think that most of us you know, at OrthoVirginia we can see any patient any day. We have same-day appointments every day for anybody that wants to be seen. I think those types of initiatives and patient experience and patient care initiatives are the things that really allow the mega groups to stand apart.
Speaker 2:Right, right. So overall, in terms of the entire consolidation matrix, which I mean the hospitals are not innocent either, right? I mean, do you want to talk a little bit about hospital consolidation? You and I have seen a tremendous amount of that in our careers.
Speaker 3:Yeah, hospital consolidation has been obviously what's driven a lot of the changes in healthcare over the last 30 years. I think the problem is or at least I believe, and this happened at the end of the Trump administration was the elimination of the inpatient only list. It was reinstated, obviously, under President Biden, but I think that the writing's on the wall for the inpatient only list. It's only a matter of time before the inpatient only list goes away. I think hospitals and health systems are incredibly worried right now. Even if you just look at what I do as a hip and knee surgeon, with total hip and total knee and now total shoulder, moving from the inpatient only list, hospitals have lost a significant amount of revenue.
Speaker 3:I can tell you, Doug and it's not anything that I can't disclose, I have two large healthcare systems right now that employ well over a hundred orthopedic physicians each who are interested in divesting themselves of those orthopedic physicians because they're worried about the financial impact of everything that's happening in the healthcare ecosystem.
Speaker 3:They tell me that they're subsidizing each orthopedic surgeon within their system between $200,000 and $300,000 each and they're subsidizing spine surgeons upwards of $500,000 or $600,000. I think, if you look back at your time in resurgence and I look at my time in North Virginia. That kind of makes sense, because where we gain traction and where we have the ability to generate revenue for our physicians is through our ability to have ancillaries, and so the hospitals and healthcare systems when they hire physicians, the physicians many times there are physicians who have joint venture ASCs and the like still, but many of them don't have that in place. So there is some subsidy that has been applied to orthopedic physician compensation across the country and the employed physician model, and so I see little cracks happening right now and certainly if the FTC does enact the policy to get rid of non-competes, at least for the for-profit hospitals and healthcare systems, I think you'll see significant disintegration of the employed orthopedic surgeon model.
Speaker 2:Right, yeah, that's pretty impressive. I didn't know that. So in terms of the public, then okay. So now let's make you secretary of HHS or director of CMS and you're kind of responsible for the musculoskeletal care of the nation. What are the bad parts about consolidation that make your job more difficult? What's what's not in it for the patient? As we we talked about the positive things about consolidation for patients, but what's what's some of the bad stuff for patients in terms of consolidation? This is no way critical of OrthoVirginia or anything else?
Speaker 2:It's just just to make sure the way it is.
Speaker 3:You know that I made the move to do what I'm doing now at OrthoVirginia because I really believe in the concept of a value-driven musculoskeletal healthcare and I've moved past orthopedic-only healthcare to musculoskeletal healthcare because I think it my naivety. When I started this journey 25 or 30 years ago, my goal was honestly to get every dollar of the waste of money within our health system back to our patients. I think I realistically now, or pragmatically, don't think that that's ever going to happen. I hope to be able to contain the increase of cost, but I don't think it's going to go back to patients. I just don't think our system's going to go back to patients. I just don't think our system is designed to allow that to happen.
Speaker 3:I think that the problem right now is that any of that excess value that occurs within the health system, so much of it's going to payers and, at least in Dave's naive view of the world, if there's excess value within the system, it should be going either to frontline folks like orthopedic surgeons or it should be going to hospitals and healthcare systems that provide that care.
Speaker 3:And so if, as I look at consolidation because consolidation has occurred so rampantly on the payer side we're all scaling up to basically achieve the same thing. So we felt under leveraged when the payers got really big and now we're over leveraging because we want to exert that leverage. However, we can exert that, whether that's on block time at the hospitals and healthcare systems that we work with. Where I'm really trying to focus and hopefully this is a positive, not a negative is I'm really trying to focus on creating more value-based incentive opportunities where we manage the upside and the downside of patient care, at least in the musculoskeletal population. So I wish that CMS and Health and Human Services would focus a little bit more on some pragmatic approaches to not only having hospitals and healthcare systems manage risk but allowing other parties, like big practices like ours, help to manage that risk for the future, because otherwise we continue just this rollercoaster ride to the bottom.
Speaker 2:I hear your MBA speaking there and that what you're let me re paraphrase what you're saying. See, if you agree with this is that for ortho Virginia specifically, you're positioning ortho Virginia for the longterm value-based plate, where you're a relevant I hate to use the word provider, but provider of orthopedic musculoskeletal services for the Virginia area, rather than seize every dollar while you can.
Speaker 3:So it's got to be the long-term play. I know that we as physicians we feel victimized in many ways I don't know how else to put it but I think we all worry about the short term, but I think that the big play in musculoskeletal health is the long-term play. I do think that value-based care is better. You know and I look at, I think there's some downsides to being a large group, but one of the upsides are for me and our value based contracts. My physicians, my surgeons will make between 25 percent and 400 percent more for doing the same amount of work. If we manage the risk and we manage patients appropriately, that puts the risk on us. We could lose money too, but we haven't. We don't. We've managed that risk.
Speaker 3:We think relatively effectively and we get and we are getting patients out of the higher healthcare cost settings. I know hospitals don't want to hear that, but there are always going to be a subset of our patients that need to be cared for in hospitals. I want to maximize what we do with our hospitals and healthcare partners, but I think for everything else we need to get it out of the hospital. I think for everything else we need to get it out of the hospital. I think in orthopedics we've proven that to be the case. It doesn't have to be all at ortho Virginia facilities, but in lieu of anything else happening, we create our own facilities because nobody else is doing it.
Speaker 2:Very good, now, that's good. I appreciate that, regardless of who wins the election four years from now, where do you see the effect of consolidation over the next five years or so in terms of the orthopedic space, and then, if you're so bold, even past that?
Speaker 3:So I probably have some different views on this than most other folks that are out there. Obviously, to date, as you're well aware, in your previous position with Macademy our government has largely stayed silent on the consolidation that's occurred within healthcare. I think that probably and I read articles from legal scholars who think that there were plenty of opportunities for the government to win and some of the things that have happened I think those ships have sailed and we are where we are, so consolidation is a real thing, I think. For me it's. The interesting thing is going to be, as I kind of alluded to earlier, what's going to happen with employed physicians, not just orthopedic surgeons, but employed specialists within hospitals and healthcare systems. It's not that I see a mass exodus coming, but I see people leaving if those non-competes are abrogated, or physicians looking for other opportunities out there. So I think that that's going to create in my world. It's going to make the bigger groups even bigger, because I think that if people are leaving in that employed status, it's not practical in today's world that you can take out a loan and start your own practice anymore, so you're going to need to have huge access to resources to be able to establish new practices. So I see further consolidation in our world.
Speaker 3:On the private equity front, I think, as you're aware, it's been interesting there's been a lot of private equity events happening within orthopedics, but this whole concept of the second bite of the apple has been a little bit elusive in these orthopedic platforms. So I'm not as high on private. I have nothing against private equity, I think it's just a business model. But I'm not as high on that conceptually for the future as some others. But on the other hand, those folks have huge access to capital and maybe, since they have that access to capital, it's always going to be that way. I don't see, with any of the political changes occurring in the near term, any changes occurring with the bukas, the big healthcare payers. They're going to continue to grow and become even bigger. I suspect, and I still suspect, the hospitals and healthcare systems are going to continue to enlarge as it makes sense for them to do so.
Speaker 2:Wow, that brings up a bunch of questions, and I have nothing against private equity either, but there is a different flavor, I think, between North Virginia and a orthopedic mega group that was acquired by private equity in terms of the very basis of it, right, because y'all remain totally, 100% in sovereign control of your destiny and, to your point, your value programs and things like that, what's important to y'all, right?
Speaker 3:Correct. I think that, as I always talk to my shareholders or physicians around the country, as I always talk to my shareholders or physicians around the country.
Speaker 3:private equity has exposed an opportunity to sell your autonomy and control, but basically you're giving up more autonomy, more control, for dollars, and you and I both have heard every private equity presentation that we're not going to have any impact on clinical care. By definition, you have to have some impact on clinical care because if you're going to take 30% of, or whatever that number is of, any physician's income and apply it, that physician has to do something to make up that difference. So that's either got to be in the resources that you're utilizing or your efficiency and productivity have to change significantly. So it's interesting. It's going to be interesting to see what happens, I think, with OrthoVirginia.
Speaker 3:I believe we function basically as a managed services organization and if folks and practices want to be part of OrthoVirginia and we're always in a robust kind of merger and acquisition phase you come in as an equal partner. Or if you don't want to be an equal partner, we can just provide the services that are really expensive services and we're able to provide them because we can have some economies of scale in the way that we provide them. So you can just buy services from us. You don't have to become part of ortho virginia, if you don't want to be right.
Speaker 2:Uh, I would be willing to bet you and I've never talked about this, but I'd be willing to bet that y'all have stayed very clear of any FTC stuff that your risks of an antitrust lawsuit are probably extremely low. Yet you continue to have mergers and acquisitions across the state and functionally yeah, I wouldn't use the monopoly word but y'all become a larger and larger force, while never really getting on the radar screen of the FTC right.
Speaker 3:Well, I think, if you look at it, even though we try to do our best to create good contracting with our payers, if we do it in a value-based approach, which really we are trying to decrease the overall cost of care, we're just trying to wrestle some of that money away from our payers. As we're doing it, we're careful about the numbers of physicians we have, about the markets that we're in, and we have 38 offices across the state. We'll have more probably by the end of the year and I think in three out of the four markets that we're in we are probably the largest player. But I think we provide great access, we provide great patient experience and we still provide the lowest cost of care in every one of our regions. So I think that's hard for anybody to look at and say that this is not achieving the aim of what we're trying to accomplish within health care right, I think when, I was I wasn't explaining myself for a while.
Speaker 2:I think, like where I live, there's functionally two hospital systems and that's it. There's one smaller private practice group, but everybody else has either been acquired, quit, shut down, joined, whatever. And I would go as far to say that neither hospital system has been excessively predatory or anything that would look like antitrust. It just was a nature of the beast, of the way that things go, and I think that y'all, y'all are probably experiencing the same thing that, through good intent, you more or lesser being able to merge and acquire that will.
Speaker 3:That. That's our goal at least, and we take seriously I take seriously our work, our collaboration with the hospitals and health care systems that we work with. We certainly try to take care of the needs of our community. We see all players. You know sometimes private practices get this hit that all they want to see are the well-insured patients. We see everybody. Our rate of federal payers is the same as everybody else within our state. So we're doing our share, I think, on all fronts, and frankly I think and I've talked to our Secretary of Health and Human Services here in Virginia I think we can provide better and cheaper care, for example, to Medicaid patients within the state, but the state just doesn't have the wherewithal to pull that trigger.
Speaker 2:And I'm very familiar with your practice and I would fully support everything you said there In terms of, say, the things like bundles, other things that are coming up that we always hear forever, and other value-based programs for orthopedic surgery and other musculoskeletal services. You got to think that consolidated groups are going to be better able to negotiate and actually pull these contracts off, as opposed to smaller groups, where that would just the lift on that just way too heavy.
Speaker 3:So the further down this, this pathway of value, we go, the more expensive it becomes to develop your approach to it. So the procedure-based bundles are one thing. We all have procedure-based bundles. We may have centers of excellence, which are a different kind of procedure-based bundle. Basically and I think most of us even small practices can probably relatively effectively manage the procedure-based bundles.
Speaker 3:As the work of Kevin Bozic and the folks at Duke start to look at condition-based bundles, it becomes a little bit more complex, because you have to then take into account, if I see somebody with a diagnosis of knee osteoarthritis and I'm going to be paid X number of dollars per month to take care of that patient, what happens when that patient goes to their primary care physician or does this or does that.
Speaker 3:So there's a lot more coordination of care. And then if you look at where I'm trying to get with OrthoVirginia, which is to jump over the condition-based bundles to basically subcapitation for musculoskeletal health, what I would like is our big payers to say okay, OrthoVirginia, for non-emergent care, we're going to pay you per member per month for our population of patients. You manage them. If you want to give them all low value care, that's your dollars that you're spending on those patients. If you want to provide them with high value care and you can save money doing that, then whatever you're saving goes to you. But that requires it does require people and it does require an expense to be able to make sure that you're managing this thing, managing these aspects effectively. You have to have actuaries, you have to have lots of different aspects of this that we, as orthopedic surgeons, haven't historically thought about.
Speaker 2:Yeah. But to and to your point, though if you're doing these condition-based bundles or the subcapitated plans on that, you've got to be consolidated to have all the required people, cause if you have nothing but orthopedic surgeons, you can't do this. You have to have other types of healthcare providers and physicians within your, your network, within your group that can can deliver this lower cost, highly effective care, high value care to the patients, for the patients who don't need expensive surgery. But that requires consolidation.
Speaker 3:My surgeons are probably tired of hearing this. If the next hundred physicians we hired orthopedic surgeon, I would hire non-surgeons for the next hundred physicians. We just need to continue to increase the breadth of the funnel. The hard part is our models for a practice like OrthoVirginia was built around orthopedic surgeons. So translating a shareholder model where people own part of the company, and translating that to things like primary care, sports medicine or rheumatology or PM&R or pain medicine all of those things become a little bit more challenging.
Speaker 3:That's what we're working through and I think we're relatively effective at doing it. But those are the challenges that we have to work within to make sure that we can create a system where we're able to provide all aspects of care. If it was up to Dave Jezevar, my surgeon would not see Dougie, your trauma surgeon. So maybe a little bit different. But me, as an arthroplasty surgeon, I wouldn't see a patient unless that patient was a surgical candidate. I think that all the rest of the care should occur way downstream, at lower cost care lower than my expense or your expense and that we should be surgeons and living to the highest level of our licensure, which I think is clinical decision-making in surgery.
Speaker 2:And in a very efficient consolidated platform those patients would be immediately directed to the most valued part of the organization as possible so they could get the best care at that level rather than, to your point, the more expensive folks which are you and I, Correct, yeah, now you've had an interesting career. After the air force you were in intermountain in utah while you you in your own practice that you sold to internet in utah you were at dartmouth and I know y'all were. When you were at dartmouth y'all were looking at acquiring different places there and now at ortho, virginia. So your entire career has been one way shape or the other involved with the consolidation kind of effort, anything, any pearls or wisdom that you've acquired from this multifaceted, different viewpoints of consolidation.
Speaker 3:I think that the biggest thing, and probably what's driven me down the pathway that I've gone, is that we, as physicians, need to be involved in everything that's happening.
Speaker 3:Not all of us want to take the time to do it, but then if that's the case that you believe the physician should be involved in leadership but you don't want to do it then we have to devise payment models for our leaders within our specialty so that they're able to lead within all the organizations that we're in.
Speaker 3:And I think that what I've seen is, if we're not able to have effective leadership, we're not able to have effective business skills, we're not able to develop effective quality programs. All of these things are integrated. If we're not able to do that and frankly it's expensive to do that that one of the only ways that we're able to get there is with consolidation, whether that's in a healthcare system that has a lot of resources, potentially, or if it's within a practice like OrthoVirginia, which I call a musculoskeletal healthcare system. We have everything about a hospital, everything else we have within our system. I think that's the type of model that will work the best for now, and probably at least into the next five to 10 years, to be successful within the orthopedic and musculoskeletal arena.
Speaker 2:This has been an absolutely fascinating discussion. I really appreciate you talking with us about this and look forward to seeing you again, and David, and thank you for your time so far on this AOA podcast.
Speaker 3:Thanks, doug, I appreciate it. It was great talking to you, as always.
Speaker 2:Yes, sir, and y'all look forward to future AOA podcasts on the future in orthopedic surgery. Thank, you.