by Carol Daus 
 

At the Tulane Institute of Sports Medicine—where the patient always comes first—the bottom line takes care of itself. 

With only 21Ό2 years under its belt, the New Orleans-based Tulane Institute of Sports Medicine (TISM) is one of the fastest growing academic sports medicine and orthopedic practices in the country. To explain this growth, all one has to do is look at the credo of Thomas Frist, MD, the CEO of TISM’s parent company—HCA. Frist stresses that if you take care of the patient, the bottom line takes care of itself. 

Frist’s philosophy is mirrored by Michael Brunet, MD, medical director and founder of TISM, who has always put patients first during his 20-year career as a nationally recognized orthopedic surgeon and pioneer in the development of sports medicine as a specialized field. According to Brunet, what makes TISM unique among academic-based sports medicine centers is its relationship with for-profit HCA. TISM is part of Tulane University Hospital and Clinic, which was acquired by HCA in 1995 through an 80-20 financial joint venture and a 50-50 board partnership with Tulane University. The agreement was the company’s first transaction with a major academic medical center and the hospital became for-profit even though the 300 physicians remained employees of the nonprofit university. “I don’t think there is any other organization in the United States that is like us in that we’re a hybrid between an investor-owned company and a nonprofit teaching school,” says Brunet. 

Barton Buxton, EdD, associate vice president, business development, Tulane University Hospital and Clinic, stresses that the relationship between HCA and Tulane has been successful because of the nature of the sale agreement. “The academic affiliation agreement maintained the integrity of the medical center, so it became clear that there would always be a great emphasis placed on teaching and research,” says Buxton. “Since we’re a hospital-based clinic connected with a medical school, we have medical students, residents, and fellows, who are all working under the auspices of Dr Brunet.” 

By focusing on its commitment to provide the highest-quality sports health care and to assist in the prevention of athletic injuries and disorders, TISM has become a major center in the Gulf South for athletes at all levels. To say that TISM is a success story would be a gross understatement. TISM has projected its October 2000 billings to be about $660,000, compared to its first month of operation in 1998 when billings were $98,000. Patient volume has also increased by about 27% in just the past year. 

Brunet’s vision was to locate TISM in a place that was easily accessible to his patient clientele. As a result, TISM now occupies the first floor of Tulane University’s student recreation center, which is just 25 yards away from the university’s practice football field. The 120,000-square-foot facility is also situated two miles away from the Tulane University Hospital and Clinic in downtown New Orleans. 

From left are Turner “Tab” A. Blackburn, MEd, PT, ATC; Michael Brunet, MD, medical director and founder of TISM; and Barton Buxton, EdD, associate vice president of business development.

Turner “Tab” Blackburn, MEd, PT, ATC, director of physical and occupational therapy at TISM, stresses that being located in the middle of the Tulane University campus has benefited the practice. With 10,000 students on the Tulane campus and 6,000 students at the Loyola University campus, which is located four blocks away, Blackburn points out that “there is never a shortage of potential patients, whether they participate in the university teams, intramurals, or fraternity and sorority activities.” The student health clinics also work closely with TISM in referring students who have orthopedic problems. 

Another factor that sets TISM apart from many other sports medicine practices affiliated with academic centers is its comprehensive range of services. The only deficit service that has prevented TISM from becoming a one-stop shop for sports medicine is an on-site surgery center, but its management team is currently exploring the possibility of adding surgical suites in the near future. “We already have an eclectic mix of services, which allows us to function as an independent entity of the hospital,” says Buxton. In addition to injury management and rehabilitation, TISM offers an advanced biomechanical laboratory with a full-time biomechanist and on-site diagnostic capabilities, which includes both general film and MRI technology and electromyographical analysis. The facility also has a pool, a huge physical therapy gym, 14 examination rooms, a special procedure room, and a file room. 

According to Brunet, one of the strengths of TISM is its biomechanical laboratory, which utilizes the latest advances in high-speed, digital video equipment and computer-enhanced 3-D analysis to study athletic performance, movement, speed, balance, gait analysis, acceleration, swing analysis, and throwing analysis. This technology can provide a baseline of performance that can then be used for comparison purposes after rehabilitation or for performance modification training. “What’s nice is that an athlete with an injury can come and not only be treated for the injury but can also learn how an injury can keep recurring,” says Brunet. “These tools allow us to scientifically look at an individual’s performance to head off future problems,” he adds. 

As part of the biomechanical laboratory, TISM offers a golf biomechanical analysis program, which allows staff to identify problems with stance, swing, and how the clubs are held. The ability to isolate specific areas of difficulty and to record this information for future analysis provides golf pros with the tools necessary to develop strategies for improvement. 

Blackburn points out that being located in the middle of a busy physical therapy clinic is one of the best attributes of the biomechanical laboratory. “Some practices have located their biomechanical labs in warehouses or buildings that are not conveniently located, so there’s a problem with usage,” he says. As a result, TISM’s laboratory has been adequately supported from a financial standpoint. 

Buxton adds that the biomechanical laboratory has also made it possible to track quantitative outcomes studies, which helps in documenting information for insurance companies as well as for research. Currently, an anterior cruciate ligament study is being conducted using gait analyses both pre- and post-surgery. 

Another strength of TISM is its on-site diagnostic capabilities. Complete imaging capabilities including MRI provide quick, comprehensive injury analysis without requiring patients to leave the sports medicine facility. Physicians are on staff to read both radiographic and MRI studies. TISM also has an on-site radiologist who is a musculoskeletal expert, Edward DeMouy, MD, professor of clinical radiology/clinical professor of orthopedics, who supervises and reads MRI scans at TISM. 

The physical therapy department at TISM also features state-of-the-art technology that plays a critical role in the treatment and rehabilitation of sports-related injuries. Emphasis is placed on balance and vestibular training, using equipment that is specially designed for these exercises. “Many sports medicine clinics focus entirely on strength, range of motion, and endurance, but we’re one of the few places that also focuses on balance to help every patient function at a higher level,” says Blackburn. 

Each of TISM’s professional staff has a minimum of a master’s degree and everyone has an opportunity to participate in research projects. TISM has its own research group that meets monthly to integrate Brunet’s and other clinicians’ research. “One of the beauties of having a relationship with an academic institution is that you have a large number of fellows and residents who work with you,” says Buxton. Residents do an equivalent of a dissertation when they are assigned to TISM. 

From left are Turner A. Blackburn, MEd, George A. Stylianides, PhD, and patient Kimberly Morand, in the foreground.

One unique aspect of TISM is its role in community outreach, which came about years ago because of Brunet’s interest and expertise in this area. TISM provides comprehensive medical coverage, event coverage, and preseason physical examinations to about 30 high school athletic teams, of which about 10 are located in the inner city. “HCA supports us completely in our commitment to helping high school athletes,” says Brunet. “By working with the schools and their insurance program, we’re able to treat students in a private hospital setting rather than sending them to the county hospital for sports injuries.” TISM also conducts weekly walk-in clinics on Wednesdays and Saturdays for high school football players. 

According to Buxton, this community outreach program is especially important since the city of New Orleans and local school parishes had contemplated stopping high school football programs due to the increase in injuries and the patients’ inability to pay for medical treatment. Brunet worked with the school boards of local parishes to create a high school insurance plan to cover these athletes. The program, which used to be conducted out of Tulane University Hospital’s emergency dependent, was transferred to TISM in 1998. “The number of kids we’ve reached with this program is phenomenal,” says Buxton. 

In addition to the high school level, TISM has formal agreements to serve as the health care providers for all of Tulane University’s sports programs, as well as the sports programs at Loyola University, Xavier University, Delgado Community College, Dillard University, and Southern University (New Orleans). TISM is the official provider for the New Orleans Brass, the local East Coast Hockey League (ECHL) team, and serves as the second opinion site for the New Orleans Saints. Brunet also acts as an independent arbitrator for the National Football League. 

Years of treating athletes led Brunet to discover that there were many similarities between the type of injuries that athletes and certain workers with physically demanding jobs experience. As a result, Brunet developed a model for treating these so-called industrial athletes and now TISM for the past 2 years has maintained an exclusive contract with the New Orleans Police Department, which includes preemployment screenings, wellness programs, and injury management and prevention. “This is an important program because for every police officer out of work because of an injury, there’s one less on the streets,” says Buxton. “Our goal is to keep them healthy and back at work.” 

Another new area that TISM hopes to develop more fully is women’s athletics. The fact that Tulane-Xavier National Women’s Center is one of 17 facilities designated by the Department of Health and Human Services to further develop medical services for women makes it appropriate for TISM to work closely with the center to create programs that benefit the female athlete. “We’re seeing continuing growth in this area and our expertise and affiliation with the National Women’s Center present us with an excellent opportunity,” says Brunet. 

Being recognized as a major sports medicine center in the Gulf South, TISM has been on the forefront of the trend to offer patients less invasive procedures, such as arthroscopy and endoscopic treatments. “The whole idea is to get people out of the realm of the hospital faster and to provide more outpatient surgeries—all with fewer complications,” says Brunet. In terms of new surgical techniques, TISM has been focusing heavily on cartilage transplantation and ligament reconstruction of the shoulder. Treg Brown, MD, and Deryk Jones, MD, both assistant professors and orthopedic surgeons, have worked together to create a protocol for ligament reconstruction of the shoulder and they are also working on the same application for the hip. TISM is one of only a few academic centers in the country working on that procedure. 

Although everyone expected TISM to be successful, its enormous growth rate in such a short period of time has caught just about everybody by surprise. In its original business plan, the goal was to achieve a 33% return on investment in 5 years. In the end, that goal was achieved in 2 years and in less than 3 years the return has been 46%. Due to this continuing growth, TISM officials are looking at ways to expand its provider base and recently hired a physician extender, who in addition to being a physician’s assistant is a former athletic trainer. Since it was opened 2 years ago, TISM also has hired two sports medicine fellows/orthopedic surgeons and a physiatrist. 

Buxton notes that the next step is to create an on-site outpatient surgery clinic. “If we could set up two or three surgery suites, we would never have to leave the premises—we’d have everything.” A business plan has already been written to expand in this direction. The problem stopping TISM right now has been the soon-to-be-released federal guidelines for Medicare Ambulatory Payment Classification (APC) groups. “After assessing these new guidelines, we will be in a better position to understand what reimbursement for orthopedic outpatient surgery will be like in the future,” says Buxton. 

Whether or not TISM takes the steps to become a one-stop shop for sports medicine complete with surgical suites, the fact of the matter is that the institute has already positioned itself as a leader in sports health care. It is no wonder that after analyzing TISM’s success rate (both financially and clinically), many orthopedic and sports medicine practices around the country have asked how they can replicate similar programs. Buxton always replies by going back to the basic model set forth by both Brunet and HCA, “In this field, if you focus on providing superior patient care, you will almost always be guaranteed success.” 

Carol Daus is a contributing writer for Orthopedic Technology Review.