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Nate Kaufman
This is Nate Kaufman with the Healthcare Bridge. You can find us under The Common Bridge, which is Rich Helppie’s podcast. Our purpose is to provide an insider’s perspective on our crazy healthcare system. There are lots of academics and policy wonks out there who talk about what we need to do to improve our healthcare system. My feeling is, if you want to know what to do to improve the healthcare system, let’s talk to people who actually deliver healthcare. So today, our guest is Dr Rod Oskouian. Welcome, Rod.
Dr Rod Oskouian
Hi Nate, how’s it going? Thanks for having me on.
Nate Kaufman
My pleasure. Rod is a world renowned neurosurgeon practicing up in Seattle. Rod, why don’t you give us a little background of your origin story and a little bit about your current practice.
Dr Rod Oskouian
Thanks. I appreciate you having me on, Nate. I grew up in Seattle, and interestingly enough, I grew up at a time when technology was starting to take off, and the school I went to, all the kids’ parents were from Microsoft except for mine. Mine were the classic immigrant story. Both my parents worked really hard. We grew up with nothing. We had a one bedroom apartment for all the kids. Computers were really popular and I remember I scraped everything I had to get my first computer. But all the kids I went to school with ended up going into tech, I was the only one that went to med school. I did my undergraduate work at the University of Washington, and then I went to UCLA for medical school. I did my residency in a really famous program that John Jane used to be the chairman of; very academic, very traditional training, he wouldn’t let you graduate unless you had 100 or more papers, you had to have 95th percentile on your boards. And then he made sure that you went into academics. If you went into private practice, you would be disowned from the family. I spent a year in New Zealand and Auckland and that was fascinating, Nate, because for me, it was the first time where - it’s like when your mom and dad let you go out with the credit card - I got out of this closed system in Virginia, University of Virginia, it was very traditional academic work, seven days a week. Everything was the same way, it was very regimented, it was a very classic American healthcare system, where it doesn’t matter if you’re 90 or 60 years old, everyone got the same treatment. In New Zealand, it was my first experience where they just have a different philosophy about surgeons, neurosurgery, tertiary care. So it was a great time in my life. I spent a year there, and my wife was a pediatrician, took the year off, and we had a great year. We just had our first daughter, and she was about one year old. Then, just because of my training and my background, I was only really looking at academic jobs, so I was looking at UCLA and some some jobs on the East Coast. I ended up at Swedish because I just knew a lot of the people there at the time, and there was a lot of stuff going on in Seattle. It was just when Swedish had decided to go into neurosurgery and they wanted to have a neuroscience Institute. I remember I had to convince my boss that it was going to be an academic practice that I was going to have. He made me swear that I would have fellows and that I would continue that UVA tradition, which is to publish and to have a fellowship and continue to go to all the meetings and all the stuff that academic surgeons do, write grants and write books. He really preaches it. I was really fortunate because when I came back to Seattle I was able to reconnect with all my old friends. There were so many cool things happening on the tech side that I’ve been able to get involved in. For example, we started the Seattle Science Foundation, which is now the largest online medical education platform in the world. I think last year, we had 23 million views. I’ve been in practice now for almost 18 years, and it’s incredible to see how much things have changed, even from when I started, Nate.
Nate Kaufman
Well, you anticipated my first question. You are in a practice with four other physicians. (Dr. Rod Oskouian: That’s correct, right.) And you’re known as folks that do complex spine work, so you’re a regional referral center. Let’s start with how has the practice of neurosurgery changed over the last 20 years, both from the standpoint of clinical practice - because few people really get a chance to talk to neurosurgeons - and also from administrative aspects?
Dr Rod Oskouian
I would say that from a from a day to day perspective, from my clinical responsibilities - because of what’s happened and I think this has happened nationally - is that the smaller hospitals and the typical community practices that were here when I first started are no longer there. I think Obamacare accelerated it. But forcing the private practices to have EMRs (Emergency Medical Records) and all these things where it just is so expensive on top of everything they were doing, it forced a lot of them to hang up the shingle and they got acquired. That’s what happened to Swedish. We were a stand alone not for profit, and then we basically got acquired by Providence. And so I would say my practice is now... I’m busier than I’ve ever been, we cover more and more hospitals. When I first started, we really only covered our downtown hospital and that was it. Then we started covering all the Swedish ERs, because the private practice surgeons that were practicing in Swedish left. So then we went from covering one ER to covering seven ERs to now where we cover all of Washington when they need to transfer people, and then parts of Montana and Alaska. And then they call us from Idaho. So we cover the WWAMI states. My practice has become more of a tertiary regional center, so we get all the very complex patients. From that standpoint, it’s definitely something that I didn’t expect. On the administrative or healthcare side of it, I think it’s changed even more dramatically in the sense that when I first started there was one administrator that I worked with. And then as things have evolved now, it’s so complex that there’s this matrix in terms of the organization and, I think for me, that’s probably been the most challenging. I can’t even count, I think we’ve had five or six CEOs for our first health system and then our other health system had probably two or three. And that doesn’t include that they reorganize every few years in terms of trying to figure out what’s the best management model to have. When I look back at my residency, they didn’t teach me any of this stuff. It’s interesting, Nate, you don’t really understand the complexity of healthcare in the US until you actually start practicing, and then when you start practicing, you really realize you have no idea how decisions are made. So it’s definitely evolved and when I look back on it, I would have never predicted that these two things would be independent of each other.
Nate Kaufman
So a question about your practice. One of the things you hear in the media is about spine surgery, and there are unnecessary spine surgery going on and all of that stuff, and that Medicare could save all kinds of money if - I don’t know - we did less spine surgery. What’s your perspective on the need for spine surgery, the authorization for spine surgery and the overuse of spine surgery?
Dr Rod Oskouian
I think that’s an excellent question. In fact, it’s interesting, because most of the data they use... in fact, recently, another article came out where they only look at Medicare data, and that’s tricky. They had this paper come out in JAMA (Journal of the American Medical Association) - I don’t know if you saw it - they put spine surgery, pacemakers, TAVRs (Transcatheter Aortic Valve Replacements); all these things, they are calling [them] low value care. Then what’s always difficult - and just being an academic person - when you really slice and dice the data, they’re using Medicare data, they’re using billing data, they’re using outcomes and if you think about Medicare patients, these are the sickest of the sickest. For example, they go, okay, well, TAVRs and pacemaker infusions, they’re costly and they don’t work. That’s the message that they send out. If you look at that population, that’s what their message is. I think if you really peel the layers of the onion away, part of what’s going on is that the cost of healthcare has gone up. But where’s the cost really? When I look at our stuff, physician reimbursements have gone down, hospital reimbursements have gone up over the years. If you look at the number of administrators, that has skyrocketed so the overhead has gone up. Then pharmaceutical companies continue to do well, insurance companies do great, device companies are doing fine. But then we’re the bad guys. We’re the people that are causing all the healthcare costs, especially in spine. It’s really hard too when you have this data continue to come out. It’s really disheartening because I think they’re sending the wrong message. Actually, for example, when you look at these TAVR patients, the ones that have critical aortic stenosis where they get a stent, when you look at their overall outcomes, they actually do remarkably well. I mean, yes, these devices are expensive, but in the grand scheme of the economics of this, when they have an agenda and their agenda is do less procedures, I think you can spin the data in such a way to make it look like that.
Nate Kaufman
Do you find a lot of denials and having to do peer to peer reviews for your patients?
Dr Rod Oskouian
Yeah, all the time. All the insurance companies are guilty of this. And the policies - this is part of the problem - each one has their own policy. For example, in spine fusion, this is one we battle all the time, where they’ll say that this procedure is experimental and they’ll create their own policy. They’ll say, we have our own policy and it has to go through our medical director and our review process. And then - I’ve seen this, I think you’ve probably seen this in the news - nobody actually reviews it. It just gets denied as a first step because they don’t think you’ll appeal it. It’s interesting, in fact, I just was involved in a recent one where it finally got to the physician and then the physician said, okay, it’s approved, but it took six months to get through all this stuff. I’m really fortunate because I have layers; I’ve got a nurse, I have my fellows, I’ve got a team. But can you imagine if I didn’t have any of that stuff, like most doctors, this patient would have never ended up getting surgery.
Nate Kaufman
Well, was it a patient in pain?
Dr Rod Oskouian
No, this was actually very interesting. It was a nurse who had very difficult multiple surgeries, and she had fractured the rods in her spine so she developed this thing called camptocormia, where she was literally bent over 90 degrees so she needed to have a pretty extensive reconstruction. And just based on the previous surgeries and everything, it was very difficult to get her surgery approved. Again, this is typical; she was from eastern Washington and she had good insurance but the insurance company knew that this was going to be two or three hundred thousand dollars and they did everything they could to… I had to appeal every single thing. We finally actually got her on the schedule, but it was really frustrating.
Nate Kaufman
You mentioned earlier that you are employed by a healthcare system. There are those out there that feel that there’s a conspiracy on the part of health systems to control the doctors and to eliminate independent practice and all that. You mentioned it, I find that most, or many, neurosurgeons are now employed by health systems. Is it possible to be an independent practice in neurosurgery today?
Dr Rod Oskouian
I don’t think it’s impossible. I think you can do it. A lot of my colleagues in New York and LA... there are certain markets where you can do it. I think you could do it in Seattle. San Francisco, you would have to, unfortunately, go the fee for service model, where you set your cost, say this is my cost for my surgical fees. But you wouldn’t necessarily be able to do Medicare. You certainly couldn’t do Medicaid or some of the other governmental programs. Basically, I think it would have to have a pretty thin staff and you’d have to do all that out of network stuff, which a lot of doctors... Myself, I agree with you. I don’t think there’s some conspiracy by the larger health systems. I just think that the way that it’s set up, all the mergers that were done, I don’t think [it works]. Running a hospital is not a roll-up business where you go in and you go, okay, well, now we have 20 hospitals, and this is, I think, what’s happened with a lot of these larger health systems. They go, well, now there’s some efficiency of scale, but then, for example, let’s say if you have a pharmacy, they go, okay, we’re going to shut all the pharmacies down, we’ll have one pharmacy. We’re going to have all of it be in one place. We’re going to have HR in one location. I think with healthcare, you can certainly do that with some things, but I think it’s hard to do a command center for everything just because healthcare is so complicated.
Nate Kaufman
I sent you the article I just wrote for HFMA (Healthcare Financial Management Association) on that exact subject, that there are too many silos and nobody looking at the overall picture. One of the things that I say is health systems employing physicians is a great idea, except they don’t know how to do it and physicians make lousy employees. From your perspective, if you could give advice to a health system about how to work with employed physicians better in a time when finances are constrained or very difficult, what would be your suggestion?
Dr Rod Oskouian
I think that’s a great question, Nate, because I’ve been on both sides, where again, most health systems, especially in the larger ones, there’s no question that they have all these silos that develop. When I look at my practice, for example, there are so many things that physicians have to do from a regulatory standpoint: insurance documentation, getting our certification for our licenses - there are so many things that we have to do, credentialing - that’s one aspect of being a physician. But I think there’s another part to it - and this is where going back to my comment that they never taught any of this stuff in med school - that it’s a business. Most doctors, when we go to med school, we’re not taught about HIPAA, we’re not taught about Medicare, we’re not taught about private insurance. We’re not taught, but all these are things we need. The other thing that’s happened is these terms get thrown around and not a lot of systems - ours is the same – connect the business to what we do and the docs usually aren’t involved in that. You’d be shocked. It would be shocking for me to tell you this, but we’re not at the table when they’re making financial decisions or big decisions. For example, what EMR (Electronic Medical Record) do they want to use, what imaging system? Now, there might be docs in management that are involved in it, but there are the doctors that are on the ground. I feel there’s a disconnect between what decisions are actually made. There’s a disconnect between the physicians that are dealing with the emergency room. All of these, they’re big decisions. For example, what AI system are they going to implement from an enterprise level? They’ll get a physician who’s really smart and hasn’t practiced in 15 years, and they go, oh, yeah, well, this is a great system, we’re going to use this AI system. But then you go, oh, wow, it doesn’t integrate with our EMR or you can’t code on it, you can’t use it for your office notes, you can’t use it for billing. Well, there goes 90% of what I would use AI for.
Nate Kaufman
I always find that you have to be, number one, radically transparent with your doctors. You also have to find the right leaders, because you can’t have every doctor in the room on every decision. You’ve been the leader of this complex spine program up in Seattle. Any thoughts on physician leadership and the do’s and don’ts?
Dr Rod Oskouian
Nate, that’s something I think I’ve learned a lot along the way, and I’ve learned a lot from working with people like you, honestly, because it’s not a skill set that we’re taught. In fact, when you look at training and neurosurgery training, it’s the most elite. It’s the Navy Seals of residency. We’ve been used to, and I’ve been programmed to want to kill your competition. That’s the way neurosurgery works. The only reason you get through is because all these other people have died off in the process. That’s how that training is. So for me, in terms of leadership, we never got any classes, even the attendings that I work with, God bless them all. It was their way or the highway, that’s just how the training is. I’ve learned along the way and I’m continuing to learn. I mean, it’s one of these things. I think leadership is something that in residency medicine is not really taught well. You learn as you go along the process. Again, for me, it’s really interesting because it’s so important as you said, you want to be able to have an impact. You want to help the system. You want to try to be involved in decisions that are going to affect the spine program or how they do the marketing. And it’s something I think I’m not very good at, but I’m learning.
Nate Kaufman
I’m going to do a HIPAA violation here and mention the fact that I am aware that you had a significant skiing accident several years ago. You had surgery. You were in the hospital for some time in rehab. What did you learn being a patient that you didn’t know before?
Dr Rod Oskouian
Actually, Nate, that was one of those experiences... I think it changed my life forever. As a neurosurgeon I’ve never stared death [in the face]. I remember it was a bad ski accident; basically I had missed a turn and I went off the edge of a cliff. I really thought I was going to die, thank God there was about a foot and a half of snow that came the night before. I had a really bad landing and I broke my leg. That whole experience really changed my perspective. This happened in Big Sky, Montana, which there’s a nice emergency room there. I got great care, but as a patient you see how complex the health system is. I thought I had great insurance, I landed in ER and then everything that was happening was a learning experience for me. I even remember that the fracture of my leg was so bad I developed compartment syndrome. Then I had to go to a regional trauma center, which is Harborview, and they did a phenomenal job. But all these things, all that stuff, was “out of network.” It ended up getting resolved but you realize, okay, yeah, your insurance, what’s considered in network? If it’s not life threatening, you have to get some pre-authorization, things like that. I had been discharged home, but then the information had been relayed from the emergency room to the surgeon, and then they had scheduled my surgery. So you realize, wow, our health system - here I am a neurosurgeon - is so complicated. The thing that I learned the most, Nate, from all this is... it’s very, very interesting. This was a different health system. I think this is part of the problem that has gone on in the US and I can’t believe it took me this long to figure this out, but if you look at most businesses, or let’s say, if you have a company - who is your customer? This is what we’re doing in healthcare - it’s interesting, this is where it dawned on me - most health systems, regardless of where you are, if you ask them what’s the business that you’re in and who’s your customer, they will tell you, it’s the patients. They’ll say, well, we’re here to serve the community and we do cancer care, or we do orthopedic care, that’s what we do. I think it’s actually the opposite. I think the health system should say our customers are our doctors. So the focus should be we’re going to do as much as we can to make sure our doctors are happy, they’re productive, they have all the tools they need, whether it’s from technology or clinics. Our goal is to make our doctors as happy as possible, and we’re going to recruit the best doctors and pay them really well. Then they’re going to be very productive and in return, they will take care of our patients. I wish Medicare had that same concept. I remember my old chairman, John Jane - God bless him, he was so smart - he said, Rod, when I started neurosurgery back in the 50s, we got $5,000-$6,000 for laminectomy, now we get $500. He said, what they should do is, if you do laminectomy, they should pay you $50,000 now, if you do the economics over that period of time. I remember him saying this, it would - and I’m not saying people are doing unnecessary surgery - make it so physicians are very selective, and you would do the surgery at the right time. But instead, with Medicare and all the insurance companies, they think if they “de-value” something, make it a low value, that their costs will go down and I’m not sure you can. I don’t know if that pencils out.
Nate Kaufman
So when you had your accident, I know you looked around where to go, because it was a very complicated case. Did you shop based on price, or did you shop based on the fact that you’re an insider and you know who the best of the best is?
Dr Rod Oskouian
Honestly, it’s being an insider. That’s where, again, I think even with my insurance and everything, they kept telling me that if I went to this doctor, it would be out of network. And so I had to actually fight for myself to get that. Finally, I said, look, yes, these other surgeons can do it, but this surgeon does 400-500 of these surgeries a year and this is all this guy does. This is the group I want to go to. You want to go somewhere where they do lots of these surgeries, and so usually that’s a place that there are fellows, they run multiple rooms. They’re operating six, seven days a week and the surgeons are just very skilled at what they do. And in medicine, you want that, you don’t want someone doing one of these a month.
Nate Kaufman
What’s your advice to patients? I mean, I know - because I’m an insider - I can make a few phone calls and figure out who’s the guy or gal that I need to be referred to for a particular thing. But the average patient, there are academics saying, just give the average person the money you would give the insurance companies and let them go buy their own healthcare. How would they know where to go?
Dr Rod Oskouian
They wouldn’t, Nate. And what’s interesting, in fact, if you Google reviews on me - and I operate on 400-500 patients a year - it’s like trying to figure out what restaurant to go to. The reviews are always the people that are unhappy, and you’ll have 20 negative reviews, even for a great restaurant. The way these search engines work, for example, Google, these reviews don’t ever go down. They’re there forever. So that’s not a great way [to find a doctor]. Unless you’re an insider, I actually don’t know. That’s a great question. It’s really complicated.
Nate Kaufman
One last question, because we’re running low on time, but I’m just curious. When we hear about outcomes and how they measure outcomes, it’s infection rates, it’s re-admissions and it’s mortality. Is anybody really measuring the outcome of spine surgeries now?
Dr Rod Oskouian
Yes and no. We do lots of what’s called PROs, patient reported outcomes, and it’s very difficult because, for example, you’ll have a workman’s comp patient who you do a discectomy for, and they’re disabled for life. They need handicap parking, everything they fill out is negative, everything’s bad. And then you have the nine year old who had an odontoid fracture, who bakes you an apple pie and is doing great. So I think it’s really difficult and it’s very subjective. The future is where I think tech is going to help. I think outcomes should be the measure. How many steps do you take? What’s your blood pressure? Are you doing your PT? I mean, all these things they can track now. I see you; you have an iPhone, an Apple Watch, (Nate Kaufman: And then an Oura ring.) yeah, an Oura ring. This is another interesting thing, people are paranoid about their privacy. But, Iook, if you have an iPhone, you don’t have privacy. They already have all your data. When I show people that they’re being tracked, they freak out. I’m like, well, what do you think? How do you think these steps are being recorded? It’s their biometrics, they call it. So I think it’s going to shift towards biometrics, and I think it’ll help the doctors, it’ll help the patients. But now, for example, this is what’s done a lot, Nate, and you’ve seen this, where they use Medicare billing data. This is very dangerous. They do this for these low value procedures. And then they go and use these things called patient safety indicators, and the hospital - you would not believe this - will try to code everything because they get more reimbursement. So the hospitals will say, this patient needed a blood transfusion, they have high blood pressure, diabetes. They’re medically complex, so they get this modifier, and so they get a little bit extra money. Well, what does that do to your outcomes? Now your outcomes look terrible, because you have the sickest, and that’s what’s happened to us here. You look at my practice and go, gosh, this is a disaster, their PSIs (Patient Safety Indicator) are high, they have all these things and length of stay is this. But then when you look at it, well, yeah, we’re getting all the sickest patients, it’s a subset of the general population. So I think it’s hard to measure outcomes right now, but I think in the future, tech’s going to help.
Nate Kaufman
So I’ll tell you this, if I need spine surgery, Rod, just save me a seat. I’ll be up there and expect you to do it because you have a great program. Our guest today, Dr Rod Oskouian. I really appreciate your candor and honesty about what you think about healthcare. Healthcare is extremely complex, and a lot of it doesn’t make sense. As you’ve heard, there are a lot of opinions out there about what should be done, but one thing you should remember is if you need healthcare, seek the guidance of an insider, because your life may depend on it. Thank you, Dr Oskouian. This is Nate Kaufman with the Health Care Bridge.
