PROVIDENCE – The daily riverrun of traffic along Route 95 through the Capital City experiences what seems to be a steep canyon of buildings – beginning with the State House and ending with the hospital campuses of Lifespan and Care New England.

On one side of the highway is the Providence Place Mall; on the other side is The Foundry, a series of massive brick structures built upon a 25-acre manufacturing site that once served as the headquarters of the Brown and Sharpe precision tool manufacturing plant. Brown and Sharpe moved its facilities to North Kingston in 1964.

What remains today is the skeleton of brick buildings known as The Foundry, a mix of apartments and office buildings, a kind of living totem to the Industrial Revolution in Rhode Island.

In the former boiler room of the Brown and Shape industrial plant, in what once was a restaurant named the Spaghetti Warehouse, now resides the Providence headquarters of Ortho RI, one of the largest orthopedic practices in the state.

At a low-key ribbon-cutting ceremony held on Wednesday evening, Aug. 21, the final redesign of the interior was celebrated, transforming the kitschy remains of the restaurant into a modern health care facility.

Dr. Michael Bradley, president and CEO of Ortho RI, along with Dr. Anthony DeLuise, who has been with the orthopedic practice for some 17 years, officiated, along with Chip the Harbor Seal, the official club mascot of Rhode Island’s FC soccer team.

At a time when the entire health care delivery landscape in Rhode Island and Massachusetts is undergoing a massive redesign and restructuring, it seems appropriate to pay careful attention to the role that Ortho RI, a non-hospital centric business model, is playing in shaping the future of health care delivery.

To the north, the bankruptcy of Steward Health Care has forced the Commonwealth of Massachusetts to invest hundreds of millions of dollars – estimated to be approximately  $700 million by reporters at The Boston Globe – in an attempt to salvage six of the eight bankrupt hospitals and their real estate.

The status of two of the bankrupt hospitals still remains in limbo, scheduled to close down later this week on Aug. 31.

The property of one of the hospitals, St. Elizabeth’s in Brighton, is slated to be seized by the state under eminent domain, with the hospital operations then taken over by Boston Medical Center, pending approval by federal bankruptcy court in Houston, Texas.

Two of the bankrupt hospitals, one in Taunton, the other in Fall River, are planned to be acquired by Lifespan, the largest health care system in Rhode Island, supported by investments by the state of Massachusetts, once again, pending approval by the bankruptcy judge.

Who sings the body electric?    
Lifespan is now transitioning to its new brand, Brown Medicine. Perhaps it makes sense that the new vision of health care delivery for Rhode Island includes a breakdown of the boundaries between the states, similar to the way that Yale New Haven owns Westerly Hospital in the south.

At the same time, advances in orthopedic surgery in precision robotics, in a way that mirrors the changes reflected in the emerging outpatient trends in orthopedic surgery, are being developed by Ortho RI, a non-hospital-centric orthopedic practice.

ConvergenceRI has reported extensively during the last five years on the growth of Ortho RI, including the opening of its ambulatory surgery center in Warwick in 2021. {See link to ConvergenceRI story below.]

Ortho RI recently entered into a partnership with Spire Orthopedic Partners, a private equity firm based in Stamford, Conn.

Here is the ConvergenceRI interview with Dr. Michael Bradley, president and CEO of Ortho RI, talking candidly about the future of the orthopedics practice and the challenges faced by health care delivery.

ConvergenceRI: How important is Ortho RI’s presence in Providence?    
BRADLEY: You can’t be in Rhode Island without having some presence there. And, for us to be able to really double our size and access, we felt that was a win for us.

It was a long time coming, but overall, the [ribbon-cutting celebrating the redesign] was very, very nice.

ConvergenceRI: Can you talk a little bit more in terms of how Providence fits with your demographic and your footprint and your growth, and what that means for Ortho RI?    
BRADLEY: Of course. I think the next two, or three or four years are going to challenge some of the historical norms of health care delivery.

What I mean by that specifically is, arbitrarily, let’s take Blue Cross Blue Shield. There is a Rhode Island-based Blue Cross Blue Shield; there is a Massachusetts-based Blue Cross Blue Shield, and then, because you contract with those people, it almost creates [difficulties] with the health care delivery from crossing state lines, per se.

And, obviously, there is a fair amount of government programs that are specialized in each state. But, to be honest, we could take care of somebody from Attleboro, as well as we could take care of somebody from Cranston.

And by having the Providence office and footprint, I think we can start to reach out and say: “We think we are doing something special. And, we don’t necessarily want to keep it only in Rhode Island.”

I think you are seeing that with some of the other health systems, branching out, slightly outside Rhode Island. And Yale [New Haven], creeping in from the south in Westerly. And with some of Lifespan’s decisions recently.

I just think [the changes in] those arbitrary lines will create health care delivery that is going to be Southeastern New England rather than just Rhode Island. And so, if that is the case, then Providence becomes very, very important for us.

ConvergenceRI: A recent OHIC report looked at the changes since 2021 in orthopedic surgery. They identified a definite trend with orthopedic surgeries moving from inpatient to outpatient. One thing lacking in the OHIC report, in my opinion, was the role that Ortho RI had played in being what I would call as being a major force in the creation of that trend, with the opening of your new ambulatory surgery center in Warwick in 2021.    
BRADLEY: Correct. Yes. So, there are two different designations there. There is the Medicare definition of inpatient vs. outpatient. In the last five years, the definition of inpatient surgery has changed and morphed a little bit.

[As an example,] even if Richard Asinof had his knee replaced four years ago at a hospital that may have been deemed inpatient. And then, if you had your other knee done this year, at a hospital, [there is a] good chance that the rates that the hospital gets paid are based on outpatient Medicare rates. Even though it is the same facility, and you are spending the same amounts of time there.

But, you are 100 percent correct. Obviously, there has been a migration of cases to a true outpatient facility that does not have the ability to keep people overnight.

And, our colleagues over in the East Bay at University Orthopedics were probably a year or two ahead of us with the opening of their surgery center.

I think we have been probably growing at a faster rate and maybe been a little bit more aggressive about doing the correct cases in the correct spot, making sure we really put a priority on patient safety.

But, we’ve really done what is a trend across the country. In New England, we are a little late to the party, but I think it’s crucial for saving health care dollars. There is no doubt about it. It does save an enormous amount of money.

ConvegenceRI: What are the challenges, moving forward, that Ortho RI faces? You have developed a non-hospital centric model that seems to work, judging from all the metrics that you have developed. My question is: Where do you go from here? Do you expand in terms of creating more surgery centers? Do you consider growing or attracting more interstate commerce? Do you expand you research facilities?    
BRADLEY: Very good questions. It is probably a three-legged stool of some sort, where all of those things are important and we just have to make sure that we don’t do anything to aggressively to disrupt the balance.

I would say the most important thing is keep doing exactly what we are doing.  What the demographic of Rhode Island shows is that there is going to be an increasing need for the complex orthopedic procedures that we have [made a priority]. That is the Medicare population, the hip and knee replacements, and spine. So, I think there is going to be a continued increase in growth and demand for those.

We are going to keep growing, both organically and inorganically, as I guess you would call it. The right partners that we can take on to Ortho RI, we would consider. If there are new physicians coming into the area, recently trained, we are interested.

The next part of your question is: Do we branch out? Or, do we draw patients in from across state lines?

I think we are dabbling in both of those right now. We are dabbling with the potential satellite office in northeastern Connecticut, in Putnam. And, then we are also dabbling with possibly an office in the Norwood area in Massachusetts. And so, what does that mean? How do we do that? Is it branded as Ortho RI but it is in Massachusetts? That’s a good question. I don’t know we if we know the answer to that yet.

And then, how does our relationship and partnership with Spire, which is basically a conglomeration of practices that have combined their back-office functions. And so, it benefits us, because we now have some eyes and ears on the best practices for things like revenue cycle management, finance, and things like that. We still have full control over the clinical goings on of the practice. And then, to be honest, the strategy and growth phase is a combination of Spire folks and the physicians that still drive that.

It’s really worked well for us. I mean, we now have a network of six ASCs from New York, Connecticut, Rhode Island, and Massachusetts that we can share best practices [with], and nine distinct orthopedic practices.

We’re not going to combine and all form one name or anything like that. Ortho RI is going to stay Ortho RI. But, there are truly some benefits. And, the difference… I know, there are a lot of discussions about capital-backed partnerships.

And, we looked at every model out there for physician practice management. And, we were kind of against a straight private equity deal, because what we’ve heard from other service lines, hasn’t gone perfectly in every scenario.

Spire is a little different, because it is an existing platform. With Spire, the MSO [management services organization] part of Spire that holds its value, 70 percent of it is physician-owned. Only 30 percent of it is backed by a private equity firm, which is currently Kohlberg, and they’ve been a great partner.

ConvergenceRI: One of the major assets, if that is right term for it, that Ortho RI brings to the table is your state-of-the-art surgery techniques.    
BRADLEY: Correct.

ConvergenceRI: That, in turn, is based on what I would call a strong research base, if that is the best way to say that, too. How do you see that growing now?    
BRADLEY: You are 100 percent correct. With innovation in medicine, there is always going to be a fiscal responsibility. You see this in pharmaceuticals all the time. In surgery, it is a little bit different. Right? You don’t want to be the first person to try out a new technique, because then, it’s like, “Is this proven?” And then, you don’t want to be last. Then, you are kind of sitting out there, while everyone else has gone past you.

And so, we really stringently vet different techniques. We have certainly identified some of the precision technologies and robotic solutions for complex orthopedic cases, both joints and spine. And the key to this is: “follow the patients.” Follow them, make sure that they are doing better, have a registry.

I think our registry, I’m going to guess, I think it houses close to 20,000 patients, which has been going on for nearly 15-16 years at this point.

You summarized that very well; I think that will be a key. Our initiative in 2025 is to be partnered with an enhanced platform for patient engagement – one that houses some of the patient-reported outcomes that we need for every service line.

We’re going to take what we’ve done in spine, in total joints, and apply it to hand surgery, to foot and ankle surgery, sports medicine, and all of our different service lines.  Obviously those, from a dollar–and-cents standpoint, have created less attention in the media and in Medicare’s world, because the total joints and spine were kind of the number-one priority from an expense standpoint.

But, truth be told, we do about 1,000 total joints at our ASC [ambulatory surgery center in Warwick]. We do 7,000 total surgeries at the ASC. There is a lot of other information to harness.

ConvergenceRI: How do you avoid the problems that Steward Health Care has encountered? What are the lessons that you see coming out of that debacle in Massachusetts? What are the things to avoid for Ortho RI?    
BRADLEY: Some of my worries with what I’ve been able to read about Steward – and not just Steward – we’ve seen some issues even in our own state with the injection of capital partners.

One of the number-one issues, if you walked around our state [looking] at our health systems, is things like deferred maintenance.

I would say literally every facility, from the health system side, has had to make that difficult choice of deferred maintenance. If you do that too long, in any scenario, the upkeep and the repairs and the maintenance become astronomically more expensive.

From what I can see, there were maybe some fiscally irresponsible moves and they were not just in facilities. I mean, certainly, in other avenues, too.

You may remember when Memorial Hospital had to close. These are not easy, fast things by any stretch of the imagination.

Our lesson is: stay innovative; continue to invest in the organization, obviously, with a capital partner, there is some fiscal responsibility for returns, but if continued growth is what we need to do, then we focus on continued growth. I think that muscular-skeletal care has been in every discussion for [developing] a value-based care model, which hopefully can bring us some financial reward and yet can drive down the overall cost of deliveries.

It’s a long-winded answer for saying I hate seeing what happened to any of the health systems, but the health system margins are really, really thin right now. I think being a hospital administrator is the angel’s work right now. It’s awfully difficult. We’ll keep trying to partner with as many health systems as possible. But, as you said, we’re kind of becoming our own health care delivery [system] for muscular-skeleton care.

ConvergenceRI: Do you see a potential partnership for Ortho RI with say, a primary care practice, as a way of broadening your footprint?    
BRADLEY: We did look at the idea of almost creating a multi-specialty group at times. One of the things is, if you look at the successful and non-successful multi-specialty groups around the country, you do different things. And, you have different mindsets.

And so, what we don’t want to do is to create a scenario where we are mixing specialists and primary care and that’s a difficult scenario.

To your point, alignment with PCP groups, so that there is clearly a way to share in the savings if there is a muscular-skeletal care management.

I think you will see continued alignment. And we have fantastic relationships with multiple primary care groups, if you take a group that is innovative, like the RI Primary Care Group, I think there are a lot of wins that you can have.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?    
BRADLEY: You probably covered it at one point, and I know it is a little bit of juggling act. Several people, such as Aaron Robinson in South County, have an important initiative on the table that is related to rate parity between Rhode Island, Massachusetts and Connecticut.

I think an objective view of the goals [on rate parity] may be helpful. I mean, nobody is going to argue that it makes sense that Rhode Island gets paid 30 to 40 percent less than our Connecticut and Massachusetts partners.

When you go through the facts, how does that happen; it is tangled web. But we’re not going to be able to continue to support and recruit not only physicians but mid-level providers and  staff to Rhode Island, if honestly, there is more money in Massachusetts and Connecticut to do the same exact thing.

So, that’s a real problem, and I don’t know if we have identified it as a crisis yet, but it is a borderline crisis.