Many spine groups “work together.” A physiatrist may see patients in the same outpatient space as a spine surgeon or a neuro and ortho spine surgeon may do the same. In these situations, a joint educational conference is often held, as well. These collaborative relationships help to provide coordinated care, but all are not necessarily on the same team. If trouble ensues, a member of the team can simply walk away. This is akin to pick-up basketball, when one player is angered by a foul, they can simply pick up their ball and go home. The goal should always be to function as a team. A true team is similar to a college football team. In this scenario, all players have a role to play, they answer to one coach and they are set on accomplishing a common goal. An arrangement similar to above is difficult to create in the complex worlds of academic or private practice.
At Cleveland Clinic, we set out on this journey 20 years ago. Our ortho and neuro spine groups always worked closely. We had a combined weekly education conference and shared a fellowship. A rheumatologist was already managing patients from a medical standpoint. A decision was made among the group to form a true department, ie., single leadership, common mission and vision and true patient centric care. A “level 2” department was created. To limit threat to neurosurgery and orthopedics, a decision was made to simply take all revenue and split the proceeds evenly between departments. Internal medicine was happy to jettison medical spine as the service routinely lost money. Edward Benzel, MD, FAANS, was chosen to be the first leader. Dr. Benzel had an international reputation, was a solid leader, but more importantly, was egalitarian. He quickly appointed Robert McLain MD, an ortho spine surgeon, as the combined surgical fellowship director and Daniel Mazanec, MD, as the medical spine fellowship director. Interventional spine was added to the medical group. The concept was built around patient centered care. All patients were triaged and the concept was “right patient, right provider, first time.” A surgeon was co-localized with a medical spine provider and patients were able to move between clinic types as appropriate. All provider offices were co-localized, so there was indeed a sense of family and partnership between all pedigrees.
Over time, the Cleveland Clinic moved into an institute model and the spine group was molded into the Center for Spine Health in the Neurologic Institute. The mission and vision did not change, only the operations. In this format, a true Integrated Practice Unit (IPU) was formed; single leadership and profit and loss accounting. The Spine Center now controlled all aspects of spine care across the institute. A common vision allowed continued growth, consolidation of services across North East Ohio and creation of care pathways. The Center now includes more than 100 full-time employees and chronic pain management and psychology. Our model has shifted over the years, now employing a large number of advanced care providers (APPs).
Building a comprehensive spine IPU has been difficult. In my opinion, a number of key issues are often critical barriers. One of the first barriers is salary. At Cleveland Clinic, we are salaried and compensation does not vary based on pedigree. In many centers, one group, ie., neurosurgery may be compensated based on productivity, while the other pedigree may be salaried or compensated in a different format. This arrangement makes it very difficult to have a group of providers truly work together. Decisions around who sees which patient or performs which procedure(s) cannot be based on compensation. A second barrier is that of leadership. There must be one leader, one vision and one mission. Leadership by committee or when individual departments have say, often fails. Agendas get in the way. Remember pick-up basketball. The leader must be egalitarian and pedigree agnostic. Multiple pedigrees are part of an IPU and could create a sense of haves and have-nots. One of Dr. Benzel’s greatest earliest moves was appointing Dr. McLain as the combined fellowship director. Lastly, is co-localization. To be a department, the group must be around each other. Our group did not truly become a family, until all our offices were in the same building. Co-localization around patient care is also paramount. It is one of the answers to patient centered care.
When deciding to build a multidisciplinary spine department, group or IPU, you have to decide if you will be the Ohio State Buckeyes or weekend warriors playing a pickup game on Saturday. It is a difficult journey; expect successes and failures. The end result will be worth the effort!.
