BoneChat #126: The Intersection of Innovation, Reimbursement, and Patient Safety

We can talk about anything and everything. I thought Eric was great last week. Sort of, NASA's embracing— they're actually trying to help startups now, which is terrific.

I had a comment, if I can. Yeah. Did you pick up something that he said? I didn't want to point it out, and I don't know who all's on this call right now, but I just—

just us friends.

Yeah. And this may be particularly interesting to Mark. Um, and Mark, were you there last week? No, you're on mute. Um, So, so first off, do you know who Eric Mühlhauer is? I'm not sure I'm pronouncing it correctly. Do you know, Mark, who he is?

I don't think, I don't think so.

Okay, so he is, um, the— I don't know what his title is, but maybe CEO or COO of NAS. Um, he is not an MD, He's like the operational guy, but he is—

he's coming on right now. I'm sorry, Eric's coming on right now, Raymond.

Oh, okay.

Oh, he's in the background, so he's in the waiting room. He may be able to hear us, so keep going.

Okay, well, I'm fine with sharing this because it would be interesting to hear how he reacts to what I'm going to point out, um, if he does participate. But there was— so he was a very amazing man on lots of levels and has done a lot to keep NAS on track and organized and so forth. He's also a very strong proponent of innovation. So, Eric, are you on the call right now?

Yeah, I'm here.

Okay, well great. I was actually commenting on something you said last week, and I'd love to hear your feedback on my feedback if you're interested. Or was there something that you wanted to share before I comment on something you said last week?

Uh, no, no, this just— it showed up on my calendar and I, um, I participated last week and enjoyed it, so I just really was tuning in. I've watched some of the stuff on YouTube, so I'm familiar with how this goes. So I'm really just here to learn myself.

Got it. So Eric, we, we either have a speaker or it's total open discussion. Today is total open discussion.

So got it.

Okay.

Yep. Well, so Eric, it's great that you're on, at least in my opinion, because I'd like you to give me your thoughts on a little nuance of what you said last week, and I wanted to make sure I heard you correctly. Um, if last week, first off, we were singing your praises on how helpful what you were saying and introducing us to this upcoming summit and all that. Um, but in one of the things you said was, as NASA evaluates new technologies and you write up papers on I guess guidance documents, or I'm not sure what you call them, but not endorsements, but papers describing the particular technology. Do you remember talking about that last week, Eric?

Yeah, I do.

Okay. In that conversation, or when you made mention of that, you said you have to be very, very careful as you assess new technologies, especially ones that reduce actual procedure times, because if you— NAS endorses a reduction in procedure time, then it could come back and bite the surgeon from a reimbursement point of view. So you have to be careful. And it would almost imply to me that if a technology reduces procedure time, that's actually a negative from a spine surgeon point of view. Did I hear you correctly?

Uh, sort of. So there's, there's, there's 3 things here. Okay, so first thing is we do a lot of work with, uh, the insurance, uh, industry. So we write these things, we call them coverage recommendation documents. Because we have a group called a payer policy review committee. So all the payers, there's like 150+ of them out there. They have policies they want us to review relative to spine surgery, spine care, whatever. And the only thing that they give us, you know, a week and it's, you know, 200 pages and we, we're all volunteers, so we can't really do that very well. So what we decided is to kind of flip the script. So we started writing— the way I put it is, if we were an insurance company, what would a reasonable reimbursement policy be for a treatment? So we worked with, um, some of the insurers on this came up with a very regimented protocol. It's evidence-informed, not evidence-dictated, because, you know, guidelines are more evidence-heavy than these are. And so we put these coverage recommendation documents out. We didn't call them policies because the insurance companies didn't like that, so they're just our recommendations. And then our members use them to fight the fight with the insurance company to get proper reimbursement. So, and they're, they're global. They are used here, they're used all over the world, and they're just really for our members. We do share them with insurance companies, so a lot of times we find that they adopt them. Um, sometimes they don't. You know, Aetna's probably the trickiest one to work with, as you probably know. Then part 2 Then part 2 is we have— we're, we're just launching this innovation stuff, right? So the innovation meeting is the first foray into all of that. We just completed strategic planning, uh, actually last week, and innovation is a major priority going forward. So we're going to develop more programming, more activity in innovation, kind of come up with what I call an innovation hub. And as one of those things, what I'm going to recommend we do is basically tech assessments on new tech. We haven't done any of those yet, and it's in the works, uh, as a plan. So then the third thing is coding. So coding, we have a very active coding committee We're involved in the RUC, so we help with valuations. And a lot of times what our members tell us is we have to play defense. So there might be a code that was surveyed 20 years ago. It's got a healthy reimbursement, a lot of RVUs, because back then it took a surgeon 2 hours to do the procedure, whatever it was. Right? So if a new technology comes along and they want to be covered under that same code and their procedure time is way less, we have to be very careful about how CMS looks at this. So nothing good ever happens if CMS— CMS takes a look at a code or a family of codes, right? So a lot of times we get into a little bit of a fight with the company saying, you know, you should be, you know, you should have an undefined code for a while. The companies don't like the tracking codes. Tracking codes are viewed as the death knell. It's, I'm not going to get reimbursed. Well, you can get reimbursed, it just becomes hand-to-hand combat then. As opposed to a global reimbursement because it's a Level 1 code. So if you go into a family of codes with a better technology, that's great. But if, if it triggers something at CMS— CM— Center for Medicare and Medicaid Services— they could take a look at that code and, and then it ends up getting revalued. Based on the new tech. And so if that happens, what you've done is you've potentially cut the value, the RVUs, for that whole family of codes. It's a really tricky part of the coding kind of underbelly. Chris Kaufman, who will be at the meeting as a presenter, He's an expert in this, and he's the one who can give you direct input on this, this subject matter. He's got examples. Uh, in my book, I allude to some examples. I didn't want to put them in writing because I don't want CMS, uh, to go after those codes. We're trying to protect our members' reimbursement. That's, that's the— sorry, that's a long answer to a short question, but That's, uh, those are the 3 things you brought.

So that was super helpful. Thank you, thank you. Um, and that just helps me understand it better where I'm— and I think Tiger has written a lot about this— is unless a new technology is, uh, less or more efficient for the hospital, is less expensive, quicker, faster, safer, then you're not going to get the hospital to approve it. But at the same time, if in fact there's a huge procedural length of time average reduction, then that could come back and bite the surgeon. So it's an interesting— I don't know what you call it— and we're trying to thread the needle. Um, and so I think Mark helped me at one point very much characterize my— the technology my company has got as not so much necessarily as reducing procedure time, but making it more consistent and repeatable, which has value from an OR scheduling point of view. So I don't know, Mark, do you remember that conversation?

Yeah, absolutely. I actually, I actually just had it with another company this morning. Eric, what Raymond just said, do you see that as different or less, um, provocative than what you just talked about, being faster? I'm curious.

Well, uh, it's a good question. You know, um, sometimes it just depends on your audience, right? So if you're talking to the hospital or the health system, being consistent is ideal. And having predictable outcomes is ideal, and shorter times are probably ideal because you can free up the OR to do more procedures. Where it gets tricky again is at the CPT and the RUC. That's where— especially where new codes come into play. So the critical part of all of this is called the vignette. And Mark, well, you're probably familiar with that. So we write a coding book, right, for our members. And then when there's a new code, there's a vignette that goes with it, and that's the description of the procedure. Sometimes those vignettes are edited to add this or that or take away this or that. Our preference for new tech is that it have its own code because we don't really understand what the impact of that new tech is going to be. And again, CMS— CMS wants to give it a tracking code because they want to see the volume of usage and they want to see the, the time factor, because the three things that are in the value— there's a medical malpractice element, there's a time element, and there's an intensity element. So, um, you know, you have to be, you have to be cognizant of your audience is my point.

That was very helpful.

Thank you.

Wow. And Mark, it's perfect that you got on this call.

I was just going to bug Eric to see if he could get Aetna to stop requiring, um, uh, Allograft instead of that revolutionary Peak cage that everybody's been using for 20 years.

I know, but, uh, we have, we have a letter on that right now actually that we're, uh, we're sending out. So I know this subject.

I, I laughed out. I actually smirked when you said, uh, you know, etna's weird. I'm like, well, there was— that was part of my question.

It was funny.

Yeah, no, I'm really familiar with it.

Yeah, I'm glad you are. I would feel I would feel troubled if you weren't. I'm actually happy that you are. That's funny.

That was good. You're happy that I have heartburn? Thanks.

Thanks.

That was not the intent, but— or the implication, but yes.

No, I get it.

I get it.

So, so let me, let me kind of reintroduce you guys. I'm not sure you know each other, Mark and Eric. So, You know, we had Eric on last week. You missed it, Mark, but he's the CEO of NASA. He's a, I love the way he thinks. He's a systems thinker. I love systems thinkers. They're not outcome-based. They build better systems.

Anyway.

Yep. So Mark comes from device sales and Mark is what we call, we call it, he's a BoneChat member. We call him the, the vac whisperer because he helps startups get through the vac process. And he learns a lot about how these third-party bureaucrats think. So share your experience, Mark. You know, you do this every day.

Yeah. And thanks, Eric. It's funny, I was, I got into med device 21 years ago as one of the original spine reps who I didn't know cervical from lumbar. I mean, I was a complete dingbat. I'm a complete dingbat. With Globus. We were one— I was like one of the first Globus Medical spine reps. I tell people this story, like, David Paul was putting sales literature in the back of my truck when I met him. I didn't even know who he was. That tells you the kind of dingbat I was. And they had done $6 or $7 million in revenue total historically. I was— I think we were probably month 13 of their existence, and we kind of know what they did. And it's funny, Tiger, I finally get back on, on this 'cause I've been off for a couple weeks and I'm getting my hip replaced in 2 weeks and I'm like, finally I could talk ortho with all these ortho guys. And then I missed the NAS guy last week. I'll listen to that. I will, I will listen to the recording, Eric. So, but I, I learned through years of doing that and then a bunch of other small med device companies that are not, that were not and are not implants, how to get products approved in these— used to be hospitals and now health systems. I went and interviewed a bunch of people. Tiger Buford had a great guy on, Joe Colonna, about 5, 6 months ago. And I've sent that interview to dozens of people, dozens of companies, so that they can understand it from a perspective of a value analysis person. And because if I, if I couldn't get new products approved in hospitals and health systems up and down the East Coast, uh, the Copeland family didn't pay their bills. And, uh, you get really good at it. And, and then, uh, I, I basically started consulting for companies, teaching them what I have learned and how to do it with their products. And, uh, it's been— it's fascinating. So I hear and see all these really great technologies Um, frankly, most of them are outside of the implant business, and some are in the ICU and some are in the ED and, uh, other places. So I get a real broad, uh, uh, view of a lot of med device. And, uh, it, it, I mean, I don't think it makes anybody on this call feel better, but it's not just implants that are struggling. Um, it's everybody. Uh, so, but, but, but yeah, so that's, that's my background, Eric, and it's great. Yeah, I can't wait to listen to you. I'm going to go back and listen to last week's interview or talk.

Well, yeah, I, I, I, I follow you on LinkedIn, so I'm familiar. And, um, Alyssa Hoffman, who is the world's most amazing connector, she's the one who, um, connected me to you. And I— we tried to get you on our program last year, if you recall, so I think you had a, you had a conflict though.

So yeah, we had, I think, a graduation or a family wedding or something, because I was disappointed. I was going to go out, it was in Chicago, and I was going to go and I could not because of— I can't remember what family commitment was. So I was honored that you guys would even invite me.

Basketball, basketball game.

Somebody else's that I'm watching and I'm not playing in them anymore.

That's funny. Yeah, you guys come at the market from completely different sides, you know, like policymaking versus helping startups get through VACs.

Yeah, you know, it's funny, Eric, I was gonna ask you this. Back when I was a farmer rep and then a biotech rep, we would rely on, like I sold antibiotics and we would carry around that was the Infectious Disease Society of America's guidelines on community-acquired pneumonia or whatever. And I mean, I literally would call on Dr. Tiger Buford and say, "Dr. Buford, listen, here's what the experts now say you should be doing for this type of thing, and my product would fit in here in this type of patient." And then we did it in sleep medicine too when I was in that for 5 or 6 years. And I have seen less of that in our field, or spine. Like, is that something— and I mean, I'm not necessarily up to date on everything spine these days. Is that— am I missing that, or is there more and more of that coming? Or is that something you have to be really cautious about? You know, sort of general guidance.

Well, like I said, we've got, I think, 28 different coverage recommendation documents. It's free to our members, free to insurance companies. Companies, we do charge them, and they bought them, so I presume they are using them for those purposes. Our guidelines are free on our website for anybody to download. So, you know, it's— I would imagine they're using them. If I was in sales, that's what I would do.

So you'd be surprised though. But yeah, that's cool. I'm actually gonna look, uh, because I've not heard people ever using them and I'm sitting here thinking, well, I didn't even know they existed.

So yeah, but I'm updated a bit, you know, spine.org, uh, and just do coverage recommendations. It'll show you the list. And we're, we're constantly adding new ones. It's like we have a new one I think coming out on SI joint stuff, um, Hmm.

Yeah.

There's, there's several others.

That's a proliferation of— there's gotta be 50 SI joint fusion devices now.

Yeah. Yeah.

It's so hard to make sense out of 'em. They're all, they all look like molly bolts or something. It's crazy.

Yeah.

Interesting. Kyle, do you have any questions? I know spine's not your 4A.

Yeah.

I just have hardware in my back. That's the best I got for spinal. New invasive, I think.

Yeah.

Yeah.

I've got a couple questions. I'd love to get Eric's opinion on this because you, you see a real, you see a broad picture. So there's a debate going on around do GLPs, they're, they're, you know, I don't know, 15, 20% of Americans are on GLP-1s now. It's a miracle drug. They're finding more benefits every month. Is that going to decrease the amount of elective procedures, or is it going— and my theory is, you know, you lose weight, you don't need a back fusion as soon, or maybe Maybe you delay it forever. And then on the other side is it increasing sports medicine injuries? 'Cause when you, when you go from 230 pounds to 180, all of a sudden you're playing pickleball and you tear your meniscus. So I'd love to hear, I'd love to hear your, your, your big guess on the, the effect of GLP-1s.

Good question. It's funny, we had a long conversation yesterday with our insurance provider about GLP-1s, and what he was saying is that the insurance companies are getting hammered because there's so many people on these drugs now. It's costing them a fortune. So, so yeah, you know, as a 63-year-old soccer player still, I call myself the, uh, the orthopedic annuity for my doctor because, you know, I go into the shop regularly, so I keep my weight reasonable, you know. Um, I think it's going to balance out, you know, because the other thing you can't stop is just aging, you know. The age wave is already underway. I— you're probably right that there might be different types of injuries I mean, backs are still super complicated, so I think you're still going to get those things. Um, but you probably have more orthopedic, like knees and hips, those kinds of things, like, like Mark's going through. So it's a really good question. I'm going to take a look tomorrow at, um, uh, Orthopedic, uh, Orthopedic Knowledge Enterprises. They have a report. I didn't read the whole thing yet, but You know, I know their projections are for, you know, growth in the ortho spine market in particular to, I think, $12.5 billion in the next 3 years. I don't know what the sources of those are, but, you know, could just be the age wave.

Interesting.

I go back to my total knee days where, you know, I learned as an engineer early that every time you take a step when, heel strike, you're getting 3, 4, or 5 times body weight. It goes through your knee. And so it's a multiple of your weight. So the difference between weighing 230 and 180 is huge. Yeah.

So, well, yeah. What, what we learned in the bioengineering field is if it moves or heats up, it will eventually break.

I like that.

So—

Oh, go ahead.

No, I was just gonna say, I think, I think people will be more active. You can't stop the aging process. So, maybe it's gonna increase the ortho, you know, extremity side of things temporarily, but I would say still, you know, 80% of people have a spine problem at some point in their life. So, I don't think that's going away.

What I, I was going to comment on, I haven't had as much time as I would like to look at the literature, but I'm pretty sure there's a fair number of articles coming out on the long-term effects of GLP-1s in terms of osteoporosis or osteopenia, and then that whatever the consequences are, at least in the spine, and So I can't even really comment because I haven't had a chance to read those articles, but I'm sure if you did a Google Scholar search, you'd find a fair amount, Tiger. But then I wanted to ask Eric a comment. You mentioned last week a number that was in the— I think it was Orthono, Orthopedic Summary. And so I went to it and apparently I got to have a subscription in order to access that report, which I don't have. But you used a number from in 2030 that I'm wondering if you either misspoke or I misheard, where it was like, I think I heard a $30 billion, but I think you just now corrected and said a $3 billion increase from whatever it is, $12 billion to or, uh, maybe $15 billion. Is that— was that the number that they reported, Eric? Do you remember?

I, I don't have it in front of me. Um, it's my daughter's birthday, so I'm heading to Walmart to get some CDs anyway. But I, I think the number was this past year globally for spine, it was around $11 billion, right? And then by 2029 I think it was going to be 12.5. So that's another 1.5 billion. I can— I'll send you that report.

I have it.

But don't tell me you got it. Don't tell me you got it from me.

I won't. I appreciate that. The—

yeah.

Okay. That makes a whole lot more sense. I— because a $30 billion would be huge. So that—

no, no, no, no.

Okay, thank you.

Even I'm not that crazy.

So, um, and Eric, did you find a, a clarity on whether you have enough, um, pitch people at the Innovation Summit, or are you looking for somebody?

Uh, we're, we're sold out. Uh, we do have a waiting list. We just— one person bailed out, so that person's now in. So If you want to get on the waiting list, we can get you. But we are— we're just starting to launch the Spine Venture Village stuff for the annual meeting, and we're going to put pitches in there too. So we just decided that yesterday.

So, okay, good. Well, I'll probably just show up, and that's because if you've already got a waiting list, I don't know. I'll send you an email.

Okay.

Thank you.

Your next, next subject I'd like to throw out is spine endoscopy. So is this a growing, is this a growing area in spine? And I think there's an Asian company that has a big footprint in the US. I'm not sure who that is. Can Can somebody educate me on spine or, well, endoscopy?

If you're talking about Andy Choi's company Amplify, uh, Andy has a Korean background. I wouldn't call it an Asian company. They're in— got it—

in Orange, uh, Orange County. I know Andy. Yeah, I forgot about them.

Uh, there may be a different company, but there's 2 or 3, and then Arthrax I think is trying to jump in with single portal or dual portal.

Eloquence is the other big one. Eloquence is the other big one. We're actually, uh, starting to do programming on endo because it's, uh, it's definitely a big interest, uh, of our members. So there's Luke Kim, uh, and, um, Chol Kim, um, from California, who are going to help us with that. So yeah, it's definitely growing in our eyes.

And this is decompressions mostly?

Yeah, I think so.

That's what I see for the most part, is interest in endoscopic decompression.

Yeah, Andy's putting in his expandable TLIF, I'm pretty sure.

I think that's— that seems like that's on the— Raymond, that seems like that's on the roadmap from what I sort of hear and listen to. But I think if you had 100 surgeons interested in it, the first places they're thinking about, right, is decompressions. It makes a lot of sense. I know some people who you would not typically think of who are interested in that, who are interested in it. And I actually, I have two surgeon friends who are, are doing it. And, uh, um, I don't know to what extent or how many, but they are actually doing it.

So, and didn't VB Brothers buy Amplify recently? I think so, or they're in the process. I don't know. I was supposed to see Mark Viscogliosi today or tomorrow.

I don't know though, so Tell him hello. Tell him hello. And, and he's a BoneChat member. He just, he's been too darn busy to get on.

Yeah.

Oh, I know.

Yeah. He's, uh, oh my gosh. He's a wealth of information. He's, you know, we, we had him on one of the, one of the first presenters and, and I mean, the VBs historically just make great bets and I don't know how they do it, but they, they, they catch things early. Yeah, they're Sentinel Spine. I mean, they've done, they've done some great work. But now they're basically a PE, they're basically a PE group though. Now, you know, they turn, they took a big gamble to buy a spine property and grow it and sell it later on. It'll be interesting.

Yeah.

Yeah.

Mark wants to create a world-class organization here. So that's— he's really focused on it.

Wow.

And I'm really focused on his French operations because their headquarters is in Bordeaux. I said, if you ever want me to come and help you with an inspection, just let me know.

That's so thoughtful of you, Eric.

You know, I'm a kind individual.

There's no wine involved, is there?

Yeah, well, I would never whine. Come on.

Do they do that there?

Is that—

oh, that's— wow, what a coincidence.

I have a Bordeaux hat in my car here somewhere.

So I remember I was at Wright Medical in the 2000s. We bought a French manufacturing company, and they would have— they would— everybody, the machinists and everybody, would take a 2-hour lunch break and just pound wine. They would go, go back to their machines and work. They'd smoke while they're— smoke while they're at the lathe in the mill. And oh my God, it was like, we just said, we— you can't do that anymore. So they, they did not like Americans. Yeah. Oh, it's funny. Kyle, you're awfully quiet. I know this is not your space, but What's, what's the latest? So Kyle's kind of a, uh, he's a serial entrepreneur, a lot of experience in shoulder, foot and ankle extremities, something like that.

Well, I'm so thinking about the next thing I'm going to do, maybe the thing after the next thing, probably into the first part of '27. I think I got some IP lined up. I've got a designer helping me out with something. And I'm, I'm at a complete blank slate on what I could do with it. Do I try and stand something up around it? Do I start taking it to potential partners? Do I leave it on the sidelines for a minute and try and gather some clinical folks on board? I think there's a lot of, a lot of different ways that I could go. I guess maybe that's a question for all of you. If you had an idea that you thought was unique and potentially very valuable, but there was— you were not committed in any way to how you were going to do it, how might you start in today's environment?

I have strong feelings about this. So I— this is the mistake a lot of entrepreneurs make, is they, they, they design a baby and they think their baby's pretty, and they, they go straight into prototyping and FDA testing and FDA clearance and and they take version 1 into the market, and version 1 is not quite right. Um, so I, I think you need to test the idea every day and every week, and without any, without any major commitments. So I would talk to anybody and everybody. I don't know what kind of surgeons would use this, but I would talk to a new surgeon every day. When would you use this? Why would you use it? What would you pay for it?

Yeah, um, I think I'd like to start the step before that.

Okay.

Because I'm actually a little less worried about speeding to a final form. I'd like to pursue or think about the best structural ways to lead into that step. So it could be, it could be finding a couple of clinicians that actually become partial equity owners and you stand up a corporation around that where they're very vested from the get-go. It could be that you just try and put IP in place and you don't worry about the incorporating side of things and you start to just slow roll it that way. And there's, there's 3 or 4 steps that would happen next. Iterations of the design, engaging potential partners that are non-clinical, engaging potential clinical partners for feedback. And any of those things can happen next, or all of them can happen next, or you could move right into, let's think about, you know, bringing some money in to support some of that and what happens there. So I'm just kind of, as, as the, as the concept is taking a little more shape I'm thinking about all the different ways that I could potentially do it, having done several different ways myself in the past with various pros and cons. I've not necessarily had a very wide open space in front of me before, and I think the reason I want to be really deliberate about that is I think within the marketplace now how you organize something new is also a potential selling point. Meaning, you know, what surgeons are signed up, how tied into somebody else are you, what did you do to structure your IP, how far along have you taken it, you know, what other investors are on your cap table. All of those things can be benefits or they can be complications. And I'm kind of thinking about all of them.

Wow. Well, the early IP you file is probably not going to be the design, so you can put placeholders in place, but you're going to file multiple patents and you're going to sleepwalk into the final configuration later. So I wouldn't spend a lot of time on IP. I wouldn't spend a lot of time on NDAs and all that stuff. It's just go as fast as you can. Get, get feedback every day. Just get feedback. Test the idea. You know, we don't do this enough in orthopedics, but if you go, if you go into the tech world, I mean, I was just listening to a podcast about the Airbnb guys and they were out really early. The Airbnb guys were out in California raising money. And they said, well, what do you, you know, how many customers do you have? We've got about 30 customers in Manhattan. And they said, what the heck are you doing in California? They said, you need to be talking to every single customer in New York tomorrow. And so they flew back, they interviewed all 30 customers and they said, And they said, wow, well, the Airbnb ads with pictures do way better than the ones with text. Can you allow pictures? And so that was a game changer for Airbnb. So you gotta, you just gotta get early feedback. Yeah, you just gotta. We have a guy, we're gonna have a guy on next week that's one of my favorite entrepreneurs. I don't wanna I don't wanna spoil it, but he's just wired as an entrepreneur and he's got a, he's got a technology that tracks instrument trays, which is a big problem for distributors, medical device companies, hospitals.

Is it Hansel?

It's Hansel.

Yeah.

Yeah. Yep. Hansel. You know, do you know him? I love that guy.

Yeah. I met him back at one of the, plug and play events maybe a year ago. Great, great first impression. Yep. I like Greg.

Great. I mean, he's, he is giving away trays for feedback. I mean, he is, he's doing all the right things. His ears are wide open. He's listening to everything and he will constantly change his business model. What he'll, he's flexible. Whereas most people develop a tray tracking thing, they get it patented and they launch it and it's not quite the right product market fit. And they end up blowing 2 years and a lot of money and a lot of momentum. Anyway, I think you gotta test it any way you can test it every day. And it's hard when it's something, you know, when it's a concept, I know that's hard, but—

Yeah. I mean, that's also being very early in the concept phase. I've seen it happen in the past where in the absence of something very tangible, especially surgeons, can get caught up in the, well, that's not how things normally look, so that's not gonna work phase. And you have to be patient with that because eventually you can prove them wrong. But asking someone to kind of set their biases aside, okay, I know you got trained this way, I know you've been staring at this thing the same way for 20 years, but I want to reinvent this in a little bit of a different way. So, so take a clean look at this. That can be really hard when you've spent— when you spent a career doing something a certain way, you know. Imagine we were going to put two patellas but on the outside of a knee, you know. Maybe it's the greatest biomechanical thing to ever happen, but the moment you put that in front of someone, their first brain is going to be like, no, you've got to have your patella in the middle. That's how it anatomically— well, but If you went that route, there's technologies all over the industry that would have never come to fruition if you ended up so caught up in that. And we could all list example after example of that. So yeah, I'm pretty— I'm very early on to where I'm just being deliberate about next steps for tactical reasons, but also for the sake of worthwhile cycles of feedback. And I got, I think I gotta go a little further before I get too deep into the feedback space or it'll just be noise.

Yep. That's a good point. It's hard to get feedback on something that's ethereal. You know, it's, you can't touch it and feel it. Surgeons are, love tactical, tactical feedback. You know, they like to, they like to feel and touch and vibrations. Interesting.

Yeah.

Eric, what trends do you, what big picture trends do you see going on in spine right now? We talked about endoscopy.

Well, I think because of the physician fee schedule that came out for this year with a site-neutral, you know, category or payment I'm seeing people express more interest in getting back into starting up their own ASCs. And I like that trend because what's happening, like, in the medical field for medical societies across the board, not just spine, but, you know, 70% plus are working for hospitals and health systems now. So, the CEOs of the hospitals are saying, no, you're not leaving Friday, you got to stay here and generate RVUs. So participation in our stuff is down a bit because of that. But I think this reimbursement trend, if it stays consistent, could help people get more, you know, autonomy back. So that's a, a huge issue, and it really came about not to tell you how to build a clock, but it came about because of the— because of the sustainable growth rate formula was replaced back in like 2015, '16 with, you know, MIPS and all these macro things and alternative payment models. Those models favored hospitals and health systems. So that forced doctors to work for them because that's where the money was. And now the playing field is a little more level. So I think people are creeping back into these ASCs, and I think that's a good, healthy trend for, for NAS and our members overall. I don't know, is anybody else seeing that?

Yes, but, but I'm not sure I see where the, the employed surgeons get into— were you, were you indicating you feel like they may be getting a little bit more independence by going to those ASCs?

Is that—

oh yeah, oh yeah, going back into private practice and, or, or being part of a system that's a little more self-contained rather than the big hospitals and the big hospital systems. So yeah, it's I'm seeing some of that shift. I, I'd like to see it accelerate, frankly. It's, it's ironic though, because some of our board members are really ingrained in the hospitals that they work for. So, you know, they're seeing how the hospital is affected, not necessarily how an individual, you know, self-employed person would be affected.

So yeah, yeah.

Are the ASCs doing every spine procedure? I mean, they're doing 360s and everything, or is it just— is it all outpatient?

It's usually outpatient. I, I would imagine there are some that are a little more, um, you know, tackle the bigger things, but, you know, you, you've got to have the infrastructure to do that, so they don't want to run a hospital. So unless you're the Texas Back Institute, and then you've got all the connections.

So, um, Eric, do you have— does NASCSP have data on what procedures ASCs are performing in, um, these days? Do you guys do surveys or mark any kind of info? Do you have any of that information or not?

Uh, I do not.

Okay. Um, yeah, because I get asked that question all the time. Is ALIF or anterior spine surgeries happening in ASCs? And I'll say in a few, yes, in select patients, but not across the board because of the risk. But I don't have, you really any good data that supports that.

Raymond, the only thing I could think that you might be able to get that answer, and I'm not sure because what I see reflects what you're— you just described, right? I would say the same thing, um, is maybe Acuity has that data that you could put together based on site of service. But, but I don't know. I, I— mine is like yours, observational, you know.

Um, I wonder if Rick Phillips has that. Um, I should ask Rick. You know who Rick is, right? Spine Market. He does, he does the, he, uh, actual ASP or actual pricing by SKU numbers. Um, and so he's got really good market data. And, you know, what company and, but you can't, but, and I would assume he knows where it's coming from, but I'll have to ask him.

I bet, I'm, I mean, I'm, I'm no spine guy, but I bet you could go to 100 spine surgery center websites and just figure and just list all their procedures that they say they do. And that would probably give you, that'd probably give you, you'd probably get 80% there.

Or use that AI software that you were talking about a week or two ago. I forget what you called it.

Scrub.

Yeah. There's so many great AI tools. Yeah. Find a new one every day. But yeah, you scrub, you can scrub websites automatically or, you know, just have an assistant do it for you. Eric, what, what percentage of NAS members are surgeons versus, I don't know, academic versus administrative versus medical device companies? Mark may, Mark may know the answer.

Yeah. Well, 75% of our members are surgeons. So about 50% are ortho spine, so they did a spine fellowship. Uh, 25%, actually it's 23%, are neurosurgeons, you know, and their entire training is brain and spine, so they don't need a fellowship. Then we have the next biggest group is probably PM&R docs, about 11%, and then we've got nurse practitioners who just do spine. We've got Other, other physician extenders, um, maybe some pain management folks, some anesthesiologists. So that's the mix, 75% surgeons though.

What's PMMR again?

Physical Medicine and Rehabilitation. So those are physiatrists, those are the, those are the guys who do PT, injections, that kind of stuff.

Got it. Steroid injections.

Yeah, so like Scott Kreiner was our president last year, a PM&R doc from Barrows in Phoenix, and now he is medical director for the neuromodulation division of Boston Scientific. So it's, it's, it's like a career track for our past presidents to go work for industry or insurance.

Makes sense. Do you guys have a— do you guys talk to lobbyists in Washington, or do you have a— are you hooked up with certain politicians?

Oh yeah, we have, um, we have an advocacy committee. Okay. Uh, Dale Blazer is in charge of that. He's from Alabama. I actually run it. Um, we used to have a DC office but just got too expensive, so we shut that down. We work with the AAOS a lot. They have this thing called the Orthopedic Advisors Circle, and since 50% of our members are ortho, we qualify. So we tag team with them, and we're also part of something called the Alliance of Specialty Medicine, which is 11 medical societies including neurosurgery, ortho, ophthalmology, dermatology, And so we work with them on common interest issues because, you know, prior authorization is a big bugaboo. And so there's lots of things. And, and we're also a member of the AMA House of Delegates, so we work with the AMA quite a bit as well. So these days we're attacking it through collaboration, not trying to do it on our own.

You have tentacles everywhere. That's incredible. How big is NAS compared to Academy? I always wondered, is it like half as big, or, um, well, I don't know the Academy's numbers these days.

Last I heard, they were around 30,000, and at our peak, we were about 10. We're about 8,500 right now. It's about a third of the size.

It's still enormous.

Yeah, we have members in 72 countries also. The biggest group outside of the US is in Brazil.

Wow, wouldn't have guessed.

Yeah, they love Americans.

Oh, it's tourism surgery.

Oh well, I mean, we, we work with them. We, we send faculty down there to do training. We send faculty to, um, let's see, we go to Dubai almost every year with 4 or 5 docs and do training locally. They pay us to do it. So we're, we, we, we're fairly selective. So Brazil, Mexico, Canada are the 3 biggest groups we work with.

Interesting.

Do you guys have a stance on stem cells, you know, or PRP or those things?

That's a, you're getting, you're getting all my hot buttons.

Yeah.

I gave a presentation a couple years ago about, there was, I'm in this kind of stem cell network myself just 'cause it's a personal interest.— and can't remember the guy's name, but there's a newsletter he puts out every, every week. And 2 years ago, maybe 3, he did a study, a nationwide study about the number of stem cell clinics that had popped up. And I think it was something like 75. And they were concentrated in Southern California, Florida, and New York. Because you've got aging populations, people who have money, and people are willing to try alternatives. So I remember when Rick Fessler in New York was starting his STAR study with spinal cord injury issues, I said, you know, Rick, the big problem that stem cells have is nobody's proving safety. So he adjusted his protocol to prove safety, because that's the big problem, is, um, there's really little safety data about these procedures and a lot of anecdotes where things went wrong. You know, there's, um, some reports of people getting ocular injections in Florida and then ending up blind. And then the worry is you're putting living cells into other parts of the body and you don't know what it's gonna grow into. So trying to figure out what the catalysts are to make it grow the right way, that's really the trickiest part. So I think a lot of our members experiment with this, but I think they do it in maybe a little more cautious way. But it's still a big question. I tried to get the Academy, AOS, to write some policies on what their members ought to do relative to this. So I was looking at it more from the ethics side of things, you know, like making sure that if you're going to be involved in this, you're crystal clear with your patients about what the data says, if there is any at all. So yeah, it's, it's an issue. Um, wow. So I could, I can send you that slideshow. It's a little old, but You want to see it?

Yeah, I'd love to see it.

Yeah.

Wow.

The other big issue we're having these days is another presentation I gave. It's called The Risky Business of Non-Surgeons Doing Increasingly Invasive Procedures. Yeah, I know that rolls off the tongue, right?

But you know, um, what, what procedures are we talking about here?

Well, I looked at CPT data. There were anesthesiologists billing for fusions.

Fusions?

Yeah.

Oh my gosh.

And so, it's kind of the slippery slope. They started with injections and epidural steroid injections or nerve blocks and then it went to pain pumps. And then, it kept progressing from there. And then, The folks out there who are a little more ambitious are willing to try doing things that they might not have the background for. So, we actually have a very big group we're working with right now to outline really where surgeons should have complete dominion. So, we're calling it Patient Safety in Spine Surgery.

Because it is a patient safety issue. Try to get them to stay on the reservation. Don't drift too far away.

Yeah, well, just outline where— okay, where the data are, you know, relative to, uh, you know, bad outcomes or complications. And, you know, if you're an anesthesiologist and you've got a sudden complication and you're trying to do a fusion, what do you do? You don't— you don't know how to fix that. So yeah. Yeah. So that, that's really the issue. That's, that's another really big issue in terms of—

wow. I never heard that one before, but Mark, Mark's very familiar with it.

Oh, oh yes. I've— you, you hear the stories, you see them, you see, um, TLIF cages being put in by people who are not spine surgeons and you're thinking, how does that, how's that possible? Well, Eric was just referencing it that, oh yeah.

Well, the vertebral body's just bone, I guess. Right. Take out the disc and put something in there.

Yeah. Don't say that around 75% of the NAS members.

So it's my understanding that, uh, interspinous devices are being marketed directly to interventional radiologists. And it's hugely controversial. It's, I don't know a whole lot about that, but, um, if you guys aren't aware of that, or Tiger, I assume you're aware of that, but I've been at meetings where at least the spine surgeons are spitting bullets mad, um, about that dynamic, yet spine companies are going after it because that's where the money is.

So, but the interspinous can be like lots of bone cuts or it could just be a tether. It could be something pretty simple, right? There's different levels of invasiveness. You're talking about, you're probably talking about devices.

Devices.

Titanium. Titanium.

Yeah.

Right. Yeah. Putting interspinous distraction devices for clamps between spinous processes and, uh, fusing. Wow. Oh yeah, there's— listen, there's a— it all started sort of with kyphoplasty.

Yep.

Right. Years ago. And now it has progressed to more things. And, uh, um, I don't know, I don't know how common it is, but it's common enough to know that I know companies that are like, hey, a big part of our market push is to go after interventional pain management.

Right.

Yeah.

I've heard that a lot.

Yeah.

Interesting.

And they're getting business.

Well, thanks. Thanks everybody. We, we're at the end of the hour. Thanks for hopping on, Eric. Anytime.

Yeah.

Yeah. It's been a lot of fun.

Happy to join.

Thanks for the— Okay.

Stimulating discussion.

Awesome.

Yeah. It's always fun.

Yeah.

Be careful. Be careful in the soccer field.

You sound like my wife. She's like, have fun, be careful. Well, I can't do both. Come on.

All right, thank you.

Good to see you.

Okay, see ya.