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Elegance in Spine: Extracavitary Approaches
The delicate task of dealing with spinal problems is getting a bit less complex, says Dr. Francis Shen. Orthopedists can now remove a section of rib and approach the front of the vertebrae from the back in an oblique direction.

Endotec Beats FDA, Strikes Blow for Innovation
Endotec has struck a blow for every orthopedic surgeon who wants to develop a better device. See how the company’s founders took on the FDA and got a federal judge to charge the agency with “stymieing progress and technological advancement.” How did they do it? Read on.

From Obesity to Osteoarthritis, the Carpal Tunnel Connection
It’s certainly no surprise that Carpal Tunnel Syndrome (CTS) is an exceedingly common orthopedic malady. But, as PearlDiver’s data show, the linkage between obesity, osteoarthritis and other conditions to CTS is most surprising. Check it out.

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
$36 million invested in the last couple of months. TiGenix has more than that in the bank to fund market penetration. Then a new paper last week finds molecular cause of OA. Cartilage repair momentum is building.

Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

If orthopedics were an amusement park, private practice would be the roller coaster and working for a large institution would be the boat ride. Says Dr. Jeffrey Baum, an orthopedic surgeon with the University of Pittsburgh Medical Center, “There is a lot of drama in private practice, but there are no highs and lows as an employed physician. Like everything in life, there are positives and negatives to each of these types of practice.”

Shedding light on his own experience, Dr. Baum notes, “For years my group was in private practice. In 1995 when we sold the practice to the University of Pittsburgh Medical Center (UPMC), the local climate was such that there was a dramatic shift in who held the power in health care. The big health systems as well as insurers were trying to connect with doctors to guarantee the flow of patients. At the time there were several major entities purchasing primary care practices. Half of the practices that referred patients to us were being bought by insurers and big healthcare institutions. In order for us to maintain the practice we thought we would have to become part of a large institution, even though it would mean giving up a significant amount of freedom. Another major issue was the rise in medical malpractice insurance rates. By becoming part of UPMC our practice was able to join the university’s insurance program and save an extraordinary amount of money.”

In today’s medical landscape it can seem like the behemoths versus the little guy. Yet partnering can bring benefits to each side. Dr. Baum: “It is difficult for specialists to maintain their sanity in some markets because healthcare institutions dominate the landscape. Many private practitioners supplement their incomes by doing joint ventures with surgery centers or other entities. We took a different path. As employed doctors of UPMC, a multibillion-dollar organization, we don’t see the ups and downs of cash flow. For us that is a plus, as it provides stability. We have kept the group together, work at only one hospital, and maintain a reasonable income. Also positive is that each member of my group is only on call every six or seven weeks because there are seven partners. The most significant minus is that we have to put up with the bureaucracy that comes along with a large institution.”

Drawing back the curtain on being an employed physician, Dr. Baum says, “Those considering this route should learn about the local healthcare market and determine who the power players are, including the major insurers. Also find out if you can get privileges at the hospital of the predominant healthcare provider. And ask yourself if you want to work at one place or travel. Many large groups are going to three or more hospitals per week, which is causing many practices to say ‘enough’ and open themselves up to joining a large institution. The days of just hanging out one’s shingle are over. This is in large part due to the challenge of getting patient referrals…now insurers and hospitals control this. Going forward more and more doctors will become employed, which ultimately will create a situation where we have to practice more corporate medicine. For example, one of my partners and I are on a committee to evaluate new spinal surgical products, something we wouldn’t be doing in private practice. We sit around with six or eight orthopedists and neurosurgeons and an administrator and look at the financial impact of new products. Then there is the recredentialing committee. Recredentialing is required every two years in order to participate in most healthcare plans; UPMC asks physicians to be on this committee and yet we are not compensated for this time.”

The stability that comes with being a physician-employee is to a great extent due to the concrete benefits provided by the institution. Dr. Baum: “At UPMC we receive some tuition reimbursement, have a very good pension and savings plan, and are provided solid short- and long-term disability insurance. And our malpractice insurance is obtained through the university’s self-insured program. We don’t have to worry about shopping around every year to get a new provider. This is an enormous benefit. Another plus is that although it can take some effort, the administration will pay for improvements to our practice. For example, we have added orthopedists, but the office is inadequate. For two years we lobbied for a new office until the hospital agreed to pay for it. If we were still in private practice we would have had to borrow the money, a huge burden. Because there are eight of us we got three digital X-ray machines, worth $100,000 each; in private practice you would have to lease them. A large institution won’t spend money on you, however, unless you demonstrate the ability to make money for the institution. In the end, we still control our practice, have a business manager, and run the day-to-day operations.”

So what are the limitations that a physician-employee might run up against? Dr. Baum says, “Large healthcare institutions tend to keep tight control over the external professional relationships of their employees. For example, we are not contractually allowed to go out and participate in a joint venture. Additionally, we are contractually prevented from having any relationship with implant manufacturers. Also verboten is accepting anything from a company, including small items such as pens or coffee cups. Probably one of the biggest things to work out is called restricted covenant. This is the issue of whether or not a physician who leaves the organization can still work in the area. In some cases doctors who leave are not allowed to work within 20 miles of their previous place of employment.”

“Speaking of traveling,” Dr. Baum adds, “some healthcare facilities have satellite offices that are 10 to 20 miles away, with the requirement that physicians see patients at those locations. Another potential issue is that in some institutions, the clinical and academic orthopedists rub up against each other. In our practice, we are to a certain extent in the shadow of the academic group at UPMC. This has unfortunately affected how we work with residents. While my group has been here for almost 50 years and has always worked with orthopedic residents, as things change the academic orthopedists are working more with the residents. It is a shame that we are losing out on this because when we talk to orthopedic residents we find they love working with us because of the realistic setting; i.e., they see lots of total joints, arthroscopy, etc.”

In deciding if the employed physician route is the one for you, talk to colleagues who have gone before you…perhaps even spend time at their practices. And, says Dr. Baum, “Always have a lawyer review the contract. This decision will affect every aspect of how you practice and could last for a long time.”