"There is no getting away from the fact that our healthcare environment is changing and we need to prove we have good outcomes," says Dr. Kaul. "More than that, however, Dr. Lager and I saw the need for a collaborative practice over the years from our patient population."

Here, Drs. Kaul and Lager discuss the process of forming TOSS and what their plans are for future growth.

1. Partnering orthopedic and spine specialists creates a patient care advantage. For years before entering into a formal partnership, Dr. Kaul and Dr. Lager were professional colleagues who cross-referred patients to each other. Sometimes patients' back pain would cause biomechanical changes that placed undue stress on their joints. Other times, patients would feel pain in their extremities stemming from spinal conditions.

"We found there were an increasing number of patients who had both joint and spinal degenerative conditions," says Dr. Kaul. "In taking care of these patients, we had two separate offices and were with two separate entities, so there wasn't a good way of facilitating care. It made economical and clinical sense to form a single group to address both spine and joint issues."

After forming TOSS, the physicians were able to easily communicate with each other about their patients. "By looking at the cases together, we feel we can provide a more accurate diagnosis early on to where the symptoms are coming from," says Dr. Kaul.

2. Collaborations are the way of healthcare delivery in the future. A great deal of focus is placed on collaborations between physicians in healthcare legislation and literature. Some groups may try to fight this change, but Dr. Kaul and Dr. Lager have embraced a collaborative philosophy, thus positioning their group for further success down the road.

"Our relationship is based on collaboration of our work, and we haven't faced any significant hurdles yet," says Dr. Kaul. "As we grow and move forward, we plan to collect clinical data to demonstrate our model is the future of healthcare delivery. It is consistent with the themes of accountable care organizations, which are important in healthcare right now."

3. Performing cases in the ASC. One reason both specialists were able to come together easily was because they have similar values and believes in their approach to surgical care. "We both do minimally invasive surgical techniques instead of open procedures," says Dr. Lager. "Our minimally invasive technique allows us to bring cases into the outpatient setting."

Open surgery causes more trauma on the patients' anatomy and requires more anesthesia, longer operating times and increased rehabilitation. If possible, performing minimally invasive surgery in an ambulatory surgery center can have several advantages for patients — especially athletes who want to return to play quickly — over traditional procedures.

4. Costs of combining aren't prohibitive. There were capital costs for acquiring the equipment and materials necessary for the practice, but Dr. Kaul estimates TOSS will quickly recoup those costs. "From a business standpoint, we won't be taking too long to recoup our costs," says Dr. Kaul. "From our calculations, we found it was feasible to expand in our case."

The surgery center had to acquire the equipment to perform orthopedic cases, previously only having performed spine and pain management cases. The patient volume for making these cases profitable is there, but like all practices, TOSS faces challenges in the declining payor rates.

"There are a lot of changes occurring in healthcare, and some are governed by insurance companies trying to deny surgeons and specialists the ability to treat their patients," says Dr. Lager. "These decisions are based upon financial reasons, not quality of care. We are trying to give patients the opportunity they need for surgery in an outpatient center."

5. Expansion to other specialties is in the future. Moving forward, the physicians of TOSS would like to expand the practice into a truly multidisciplinary musculoskeletal care center. Eventually, they hope the practice will include additional specialists in interventional pain management and rehabilitation services.

"As it grows, we would like this to develop into a multispecialty musculoskeletal group," says Dr. Kaul. "The multidisciplinary approach is one of the more economical ways of delivering healthcare and improving outcomes on an international basis. Our short term goals are for Dr. Lager and me to collaborate and take care of patients."

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