Stephen Hochschuler, MD, met Ralph Rashbaum, MD, while they were both stationed at the Air Force base in Wichita Falls, Texas, before they were even specializing in orthopedics, let alone leading one of the preeminent spine groups in the country. As general medicine officers, their relationship and interest in spinal disorders grew, and both went on to focused orthopedics and spine training. Two years later, they began the process to develop their practice, Texas Back Institute in Plano, which has been at the forefront of the field ever since. Dr. Hochschuler — now chairman of Texas Back Holdings Corp. — and Dr. Rashbaum succeeded in growing their practice to include innovative concepts and technology, as well as training programs to develop spine surgeons of the future.
"Our growth process was one of evolution, not revolution," wrote Dr. Hochschuler of the practice's history. "We were, however, proactive, not reactive. We made several mistakes along the way, but because we moved slowly but progressively toward our goal, we survived the evolutionary process."
He also learned about building and maintaining a business, gaining knowledge that ambitious young surgeons are now eager to absorb.
"I think any time you are building a business, you don't win everything," he says. "You have to weather the storm. It's like a sine wave; sometimes you are at the top and sometimes you are at the bottom. You have to have thick skin to deal with other peoples' perceptions. Live and dedicate your practice to providing quality care for your patients."
Here, Dr. Hochschuler discusses the innovative elements of his practice and where spine care is headed in the future.
1. Pioneer clinical developments for spine surgery. Since its formation, the surgeons of Texas Back Institute have been committed to developing technology at the forefront of spine care. At the time of its inception, Harrington instrumentation was the standard for implants and Knodt rods were just emerging on the scene. Texas Back Institute was the first institution in the United States to prescribe outpatient Myelopathy, a decision that was controversial even within the practice.
"It is always interesting when you innovate and apply new techniques how there is a hesitancy for change," Dr. Hochschuler wrote. "As we all know, if one does a myelogram today, it is performed as an outpatient procedure as are many other spine procedure."
Texas Back Institute surgeons were instrumental in the development of the MRI scan and became the second center in the United States to do multiplanar reconstruction of CT scans. Dr. Rashbaum is credited with conceiving the initial pedicle screw and rod fixation system on a napkin, and one of the first constructs became known as the "Texas Connector."
"Now, in terms of innovation, we are looking at downstream technologies," says Dr. Hochschuler. "Those include biologics, image guidance and robotics. We're always looking downstream at new types of minimally invasive surgeries; right now minimally invasive surgery is only performed 15 to 18 percent of the time, so there is room to grow."
2. Research, development and FDA trials. The Texas Back Institute Research Foundation was founded in 1985 to support research, education and development related to spine care. Research has primarily focused on diagnostic evaluations and treatment outcomes. Most recently, the foundation has engaged in total disc replacement research and several Texas Back Institute surgeons participated in the FDA trials for several lumbar and cervical artificial discs. TBI surgeons were the primary authors and principal investigators for both the Charite and ProDisc IDE studies.
The support of Texas Back Institute Research Foundation has allowed the surgeons to become internationally involved in podium presentations and symposia. "We had a key role in the formation of the North American Spine Society, and several of our group members became members of the International Society for the Study of the Lumbar Spine," wrote Dr. Hochschuler.
He also became a founding member of the Spine Arthroplasty Society, now known as the International Society for the Advancement of Spine Surgery. Throughout its history, the TBI Research Foundation has been involved with several professional publications, including "The Spine in Sports," "Lumbar Disc Disease," "Cervical Disc Disease" and "Spine Arthroplasty: A New Era in Spine Care."
Texas Back Institute is already engaging with the technology and techniques of the future, which include:
• Image guidance and robotics
• Genetics and biomaterials
• Nanotechnology and microelectromechanical systems
• Spine arthroplasty
The practice had also formed a for-profit research foundation which participated in over a dozen FDA studies.
3. Education to further the field. Richard Guyer, MD, founded the Texas Back Institute Spine Surgery Fellowship program in 1986, which has trained nearly 100 Orthopaedic and Neurological Surgeons to date. Dr. Guyer and Jack Zigler, MD, are current directors of the fellowship, which provides a broad base of exposure to all aspects of spine reconstruction for degenerative conditions, deformity, tumor, and trauma, with a concentration on spine arthroplasty.
"The creation of the fellowship sparked the development of our weekly neuroscience conference, which is CME accredited," wrote Dr. Hochschuler. "The fellowship program also includes weekly interesting case conferences, biweekly M&M conferences, and a monthly journal club."
Fellows are also required to engage in research with the Research Foundation and present their findings before successfully completing the fellowship. The practice also welcomes surgeons from around the world to observe their technique. Education is an important part of furthering the field of spine surgery, and Texas Back Institute has spread its network far and wide throughout the process.
4. Build a comprehensive care center. Dr. Hochschuler and his colleagues realized early on in the practice's development that including a wide variety of care options was the way of the future. The practice has included physical therapists for several years and now includes non-surgical specialists including neurology, occupational medicine, physical medicine and rehabilitation, psychology and internal medicine.
Blazing the trail was not always easy and the specialists experienced many of the growing pains associated with expanding their coverage.
"There are always turf battles," wrote Dr. Hochschuler. "When we first brought in an exercise physiologist, the physical therapists did not accept him. It became a process of slow integration. When we elected to bring in chiropractors, we had turf battles and much concern."
The practice was able to overcome these challenges by taking small steps to bring these new specialists on board; they also sought out the most experienced and qualified people in the field to join the practice, which gave them "the opportunity to have members of [the] group learn from these distinguished people in their own realms."
5. Lower the cost of care. One of the biggest efforts of healthcare reform is lowering the cost of care. Dr. Hochschuler and Texas Back Institute are working on several initiatives to lower the cost of care while remaining profitable as an independent spine practice. One of the potential opportunities will be investing in an ambulatory surgery center in the future, which will lower the cost of the minimally invasive procedures performed there and enhance the practice's ancillary revenue stream.
"Our hospital chain agreed to build 30 surgery centers over the next three years with a corporate partner," says Dr. Hochschuler. "For the average spine or orthopedic surgeon, this is a great opportunity to be part of the operation structure and make ancillary income where their own healthcare dollar is being tremendously compromised. That's a huge potential lucrative area for Texas Back, and we are looking at that very seriously."
Texas Back Institute is also invested in two physician-owned hospitals, although the Patient Protection and Affordable Care Act of 2010 has restricted their growth. ASCs may be the most viable way for surgeons to own and control their surgical environment in the future.
Another initiative Dr. Hochschuler has become involved in is cost control of implants. He works with PDP, which could be the disruptive business model of the future. PDP allows providers to purchase implants from manufacturers at the wholesale price, cutting out the distributor.
"The middle man is the distribution network, which gets 12 to 38 percent of the sale," says Dr. Hochschuler. "If you can get rid of the middle man, you can lower the cost of implants. PDP has a great model."
In the future, Texas Back Institute will be looking at bundled payments and other ways to assume risk in accordance with national healthcare provider trends. Providers are also marketing their services to patients more now than in the past, and patients are taking control of their healthcare experience.
"We've got to make the patient in charge of their healthcare dollar," says Dr. Hochschuler. "We need to get health savings accounts on a bigger level so patients can shop for a surgeon or program based on quality, cost and outcomes."
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