This episode’s specialty spotlight is Scoliosis Spine Surgery! Guest Dr. Richard A. Hostin is a board-certified spine surgeon who treats a comprehensive range of spinal diseases and disorders. In this episode, we discuss the corporatization of health care, pros and cons of being in a high-revenue generating specialty, and advocating for patients.
Listen to the full episode using the player below, or by visiting one of the links below. Below is the episode’s transcript which has been edited for readability. If you have any questions or would like to learn more, email us at email@example.com.
Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto. Legal issues, simplified through real client stories and real world experiences. Creating simplicity in 3, 2, 1.
Brad: Welcome back to another episode of Legal 123s with ByrdAdatto. I’m your host, Brad Adatto with my co-host Michael Byrd.
Michael: Thanks Brad. As a business and healthcare law firm, we represent clients in multiple sectors and multiple specialties, including healthcare.
Michael: This season, our theme is specialty spotlight where each episode we’ll visit about some of the nuances that can be found from a business and healthcare perspective in the various practice specialties.
Brad: Michael today, we actually have a guest in studio, and I think we’ve known him as long as you have known me.
Michael: We go way back with our guest today. In fact, we started working with our guest when he was an employed physician on the early side of his career.
Brad: Yeah and I can tell by your body language that you want me to talk [00:01:00] about something, so let’s go ahead. Get it outta the way. Not be distracted because we do have a guest in studio. What are you gonna throw at me today?
Michael: Have you played pickleball yet?
Brad: No, but I have played whiffle ball and ping pong. Does that count?
Michael: Well, kind of.
Michael: But I’m a little snarky about it now. I have not played yet. As you know, I’m a tennis player and I’m a little embarrassed by this, but I haven’t had kind of that tennis puris attitude towards pickleball historically.
Brad: This does not surprise me at all, Michael. You do like to look down at people, audience members, especially those who don’t go to state for typing. So if you’ve never gone to state for typing, Michael is judging you.
Michael: I think you’re overplaying the typing thing, Brad.
Brad: Okay. Sorry.
Michael: Okay, as far as pickle ball, I have to admit, I’m starting to soften about it. I’m getting curious. This is not a healthy attitude to look down on something like this, and I can kind of see what’s happening. It’s kind of [00:02:00] like when snowboarding started invading the snow skiing world and all the traditional skiers, which was me, complained about how the snowboarders were messing up the mountains.
Brad: Yes. You sound like an old man. Get off my porch moment, but yeah, pickleball, I’ve definitely seen this wave of momentum definitely sweeping across the country.
Michael: I know I read several articles about it, which has kind of stoked my curiosity and, I mean, there are titles, like pickleball can save America and how it’s playing a part in bringing people together with different views. I think the draw, at least according to the articles is that it’s an easy to learn game and that people of different skill sets can play together. I recently read about the emerging dark side to pickleball.
Brad: Yes. First off, I did read that same article about pickleball saving America. That did peak my interest. It was a very fascinating article, but learning also that there’s some conflict out there [00:03:00] is actually even more fascinating.
Michael: I know. Well, like most good things, money will start to mess things up.
Michael: And so this organic, almost hippie type sport is starting to make a lot of money out there. And there is an intense battle among a few players to be recognized as the pickleball association.
Brad: Yeah. I know this is an early stage with pickleball, but when I started reading about this, learning more about the fight, it actually started to remind me about what’s happening right now in golf with the PGA and LIV, and now this is actually playing out in the pickleball world.
Micheal: Yeah. Pickleball is a little lower profile, but yes, you’re right. Apparently, the fight is among the association of pickleball professionals, major league pickleball and the professional pickle ball association.
Brad: Yeah. I knew there was an association out there. I had no idea there were [00:04:00] multiple associations out there.
Michael: No one’s gonna remember what I just said including me so we’ll just go by initials. Okay. The a PPP and the MLP are two of the first associations and they were formed organically as part of this love for the sport. They seem to coexist well together. The PPA on the other hand is newer. It was recently developed by Texas billionaire, Tom Dundon, who also owns the Carolina hurricane’s hockey team.
Brad: So is he like the MVP of the PPA?
Michael: I have no idea what you just said, but big money’s entering the picture. He was strategic so he’s acquired a couple of companies. He acquired one company that has two decades worth of player and event data for pickleball, which, who knew it even actually went back that far, but it does, it went back. It goes back to the seventies and [00:05:00] acquired the website. That’s the only website out there that organizes all pickleball tournaments.
Brad: So one thing we can learn is your name would not be on any of those websites.
Michael: This is true.
Michael: I still have not tried it.
Michael: The latest move, which kind of goes back to your LIV tour thing, is that PPA is now signing the top pros in pickleball to contracts where they sign over all of their name and likeness rights and agree to exclusively be part of the PPA. Now, mind you, this is a young sport so they’re not even the best of the best in the scheme of things, especially when you think about sports, not making a ton of money. These guaranteed contracts are pretty lucrative but they’re also extremely restrictive.
Brad: So how’s this gonna play out, Michael?
Michael: It’s in the early stages. It does randomly look like Austin, Texas is kind of the pickleball [00:06:00] epicenter and where this fight will play out. The players who sign these contracts with the PPA are starting to realize that they sign their life away. They particularly don’t like the fact that they cannot participate in the events of the other associations.
Brad: Oh yeah. That is the golf.
Michael: The only thing we know for sure is that the unifying love vibe for pickleball is at least at the pro level starting to dissipate.
Brad: So let’s get back to my question I started with. We have a guest in studio, how does this connect to him? Is he like the pickleball pro that I didn’t know about.
Michael: It’s so loose, I really read the story and wanted to talk to you about it and we’ve been through a few intense business negotiations with our guest today, over the years. We’ve worked together for a really long time and I remember it was all green pastures and fun at the very beginning, when we were talking about what it would look like to become a partner in a [00:07:00] practice. Then we all got to grow up together real fast through a couple of business deals. So it does, it reminds me of kind of the dream versus reality of getting through things.
Brad: Alright. Well, he’s sitting right here. He’s been very patient with you, Michael, on your pickleball fascination. Please bring on today’s guest.
Michael: Let’s call it curiosity as opposed to fascination. Our guest today is a longtime friend and client Dr. Richard Hostin. Rick is a spine surgeon. Fellowship trained in orthopedic surgery. Rick treats the most complex cases, including scoliosis, complex spinal deformity and advanced spine surgery. He is a UC Berkeley undergrad, OU medical school, UC Davis residency. Did his fellowship at Twin City Spine Center in Minneapolis and is currently the medical director for Medical City Scoliosis and Advanced Spine Center [00:08:00] here in Dallas. Rick, welcome.
Rick: It’s interesting. The pickleball story. If you guys knew how much I heard about pickleball amongst the retiree crowd in Texas, you’d fall outta your seats. That actually explains a little bit because I didn’t realize there was that much big Texas money behind it. So, that’s interesting. I think both the pickleball bickering and some of the stuff we see in the practice landscapes, is what I like to call people, being people. So, these types of things always play out every 20 years and every different thing, always. Some of, I think the struggles that the PGA and the Pickleball Association go through are the same kind of reasons that some of the guys doing practice contracts and bringing on new guys, kind of the same kind of mindset, which is an old school way of thinking, and there’s a young upstart and things don’t work that way anymore. You get into [00:09:00] all this stuff, and it’s just a natural order of things. I think the benefit of working with good attorneys who do this stuff all the time is that it’s hard to see something you guys haven’t seen before. A lot of this stuff, I think you have to have a little bit of a sense of humor when you’re going through these processes with things, because part of its contract and paper on law and part of its personal psychology and people. Ultimately, it’s nice to have guys, who’ve worked with a lot of people and seen a lot of different personality types to try to get deals done, which is ultimately what all of us want.
Brad: Absolutely. So I guess, based on your response to pickleball and you referred to the retirees, you are not one of the retirees, so you’re not playing pickleball right now.
Rick: Hopefully, now see, now that Byrd’s getting interested, tells me he sees the light at the end of the tunnel and maybe heading for the pasture. When you get your retirement baton, you’re gonna pick up that pickleball racket and put down the tennis racket, I guarantee you.
Michael: It’s my plan [00:10:00] B for when Brad runs me outta here.
Brad: There you go.
Rick: Yeah. I think it’s popular amongst the retirees because you can enjoy racket sports and it’s not as much running and it’s not as hard on the body so people can play more regularly and not beat themselves up and it’s hard to run around when you’re in your sixties or seventies like you do in your thirties.
Brad: Yeah, no doubt.
Michael: Well, cool. We’re glad you’re here and we are not here to talk about pickleball. I love the people being people connections.
Michael: This is so true in anything. Well, let’s start and just give the audience a little context and introduce the audience to your specialty, which, broadly, is spine surgery, but you were in kind of a very specific area of spine.
Rick: So, I mean, spine’s a fairly broad field and guys doing spine surgery can be either orthopedic trained or neurosurgery trained. Many years ago, the specialties were a little bit discreet so most of the guys who [00:11:00] did a lot of instrumentation or putting screws and rods, Harrington rods, these sorts of things, and Harington was a Texan, obviously from Houston. So Texas has a rich history with spinal deformity surgery tended to be orthopedic guys. The neurosurgeons tended to work more on spinal cords and nerves, do decompression work, spinal cord tumors, detethering for spina bifida and these types of things. Over the last 25 years, the specialties have really come together. There’s a one spine movement where a lot of the fellowships now take part of the guys as neuro and part of the guys as ortho and the training is sort of much more homogenous. Now, I would still say amongst maybe the spinal deformity and scoliosis crowd, there’s still a bit of a orthopedic bias because of the historic training programs and the older guys that went through training years ago. We’re seeing the specialties become much more sort of uniform and just vice versa. A lot of the [00:12:00] orthopedic guys are now very facile at complex tumors and intradural work and things. We still do cases with each other and again, a lot of it has to do with your individual experience and what you like to do lots of. So there’s guys whose whole practice is doing nothing but spinal tumors. There’s guys whose entire practice is nothing but very complex reconstructive spine scoliosis surgery. There’s guys that do nothing, but Kiari malformation. Like anything, whether it’s law or medicine or being an auto mechanic, if you do a lot of one thing a lot, you tend to become very good at it and very safe at it and do it well. It’s a little bit hard and spine to be really great at every super complex thing there is. Those of us who have been in the game a long time, know where our real skill sets are, where we shine and then load the boat. If we’ve got new technologies that we think would fit a patient well that maybe we’re [00:13:00] not the best at, we’re quick to bring either other guys on board or send those cases to ’em so that patients get the best outcome, which is really what everybody who is a good doctor wants, which is you fix people’s problems, you minimize your complications and you do it in the most cost effective way possible.
Brad: Sounds like the pickleball association should bring him in cause if you’re bringing orthos and neurosurgeons together and you’re doing it for the best outcome, that’s the pickleball association, bring it back to them. They need Rick to come in and help do that. Bring the right people onto the boat, as you said. That’s fascinating to hear that because I know growing up with my dad, being an orthopedic surgeon there was a big distinguishing aspect for a long time, between their different specialties and to hear how you’re coming together for the patient health, that’s a fascinating move, which I think, as you said, it’s relatively newish to the industry and especially with the fellowship aspect to it.
Rick: Institutionally there’s still places where there’s a lot of [00:14:00] tension in academic departments between who does what and who gets what referrals.
Rick: That’s politics on a local level. I would say nationally amongst the field and thought leaders, there’s less of that divisiveness and I think more press for uniformity and standardization of treatment care. I think a lot of us want to see better data and better evidence and less variability in treating patients with various conditions, not just complex scoliosis, but general spine conditions. There’s been a big push to have larger national type data sets where we really look at what are the best treatment options? What’s literature say? What are areas that require study to have pooling of data, both in the European populations and as well as here in the us? I would say as opposed to orthopedic joint replace, we are not yet as uniform in terms of [00:15:00] recommendation of treatment strategies for various conditions and that can cause confusion for patients cause Dr. A says I would do it this way and Dr. B says I would do it that way. The reality is, and a lot of times the literature is equivalent on that there’s more than one way to roam.
Rick: The person, the recommendation of the technique that’s best to fix the problem is often the technique that the guy is best at.
Rick: A lot of times there’s more than one way to do a surgery. The key is to do them safely and to have good results.
Rick: If you work in a big metroplex, like Dallas, where things are competitive, or New York, there’s a lot of very good people. So generally speaking, if you’re a guy that’s not a good surgeon who doesn’t do well with patients and doesn’t have good results, you’re not gonna survive long, ultimately. We, in Dallas, have had a few outliers, we had the doctor death guy here years ago.
Rick: There’s podcasts about that. [00:16:00] I mean, that is really an exception and that guy basically got burned at the stake. I mean, you saw that guy got life in prison.
Rick: I mean, that has never happened before because that type of thing is so, I mean, all of us who do anything in healthcare for orthopedics never see anything like that.
Rick: I mean, just completely an outlier. Most of the folks you see are looked at pretty carefully. There’s big departments with neuro and ortho guys, and there’s a lot of homogeneity for surgery results.
Brad: So for our audience members, I know the difference, but I think for them to understand when you’re doing a scoliosis surgery, what is the time commitment and staffing need for that versus a, I use the term loosely, a simple spine surgery? I know like some things are in a spine surgery can be very microscopic while scoliosis surgery is a completely different animal by itself.
Rick: Spine surgery is kind of going through some of the transformations we [00:17:00] saw with joint arthoplasty a number of years ago. If you look at the joint arthoplasty stage, joint arthoplasty largely has moved an outpatient procedure. It used to be four days in the hospital and a rehab stay. Spine surgery in the general setting is moving more and more outpatient so minimally invasive techniques. A lot of things allow the procedure to be done in surgery centers with day surgeries. As deformity surgeons with big reconstructive procedures, we are not in that boat.
Rick: Just like doing tumor arthroplasties or more complex joints, that stuff is still in a big facility. We’re, in our practice, really anchored to inpatient facilities where we have good critical care, good vascular, good cardiac coverage because they’re large surgeries and we look for institutions that have strong benches in terms of critical care needs and all the things we could do in case something happens, or we need support. What you don’t want to be doing is a big surgery in a little place without [00:18:00] a good blood bank, without good ICU, without good critical care, cause that’s when you get into trouble. Theres starting to be a bigger and bigger kind of separation between what I would call general spine or routine spine and some of the more complex reconstructive work where a lot of times we’re not even in the same facilities anymore like we used to be, because I think so many advances, some of the endoscopic decompression techniques, minimally invasive techniques, better perioperative pain management are allowing these things to be done outpatient, but scoliosis is not gonna be on that list anytime soon.
Michael: Yeah. Well, let’s pivot a little bit, cause you have had a lot of experiences on the business side of medicine and would love just your perspective on kind of some of the biggest business challenges that you see kind of in a spine surgery practice.
Rick: Yeah, I think all of us in healthcare, as physicians, have kind of seen a bit of an erosion of autonomy and what I would call the [00:19:00] corporatization of medicine. I think for some of the older school physicians who are, I’d say, 55 and up, it’s been a big challenge just to get their head around that fact. COVID in some ways has really accelerated a lot of the pressures on the practices. The challenge has been, you have a declining reimbursement environment, you have an increasingly restrictive regulatory environment and you have dramatically increasing overhead. The COVID thing has pushed the healthcare employees just outta the market. I mean, everybody is fighting to the death over every last employee to try to retain them cause there are just not enough people.
Rick: I mean, and not even kind of enough people, not even remotely close to enough people to just staff the hospitals. Much less ASCs, doctors’ offices, imaging centers. It’s really been a challenge to number one, provide work environments where you can number one, recruit and number two retain good people because you’re only as strong as your weakest link in dealing with [00:20:00] the patients and then number two, to do so in a way that you don’t start taking out loans to show up to the working. So that’s been a little bit of, I would say a challenge for everybody. Spine surgery, if you look at most hospitals, there’s only four or five service lines that are particularly lucrative for the healthcare facilities and spine surgery and orthopedics is one of ‘em, neuro, oncology, I would say, sometimes bariatrics and other things, but there’s not like an unlimited bench of every subspecialty that the hospitals have a tremendous interest in. Spine surgery practices, I would say in big metroplexes, there’s been a lot of recruitment. Everybody always wants you to bring in new guys because they see, hey, this is potential revenue growth for the hospital and we have a need, but you know, you have to keep an eye on, does the marketplace really need that? How many new guys can you absorb? What you don’t wanna do is create pressures where people [00:21:00] are being more aggressive with indications than they should be because they’re slow.
Rick: That’s really as a physician, that is what you have to guard against and we’ve always been very conservative on hiring guys to the point, waiting till we’re kind of bursting at the seam so we’re confident. Look, you know, we’re not gonna have a guy sitting on his hands and struggling for work. The COVID situation provided a tough time. When we were kind of shut down at the hospitals we couldn’t operate so a lot of guys were frustrated because they had overhead they had to cover, they had employees they had to pay and we couldn’t see patients. We couldn’t operate. You can’t do surgery over telemedicine. I think it’s been a rough couple years. I mean, I think most of the practices are now coming through it and getting back to the new normal, but it really, I think accelerated changes in the healthcare landscape very, very quickly. You saw a lot of practices roll into affiliated consolidations with either, if outside of Texas with [00:22:00] insurances or in Texas where you can’t be direct employed, either going back to university type jobs or taking jobs where you’re supported by healthcare systems to some degree, either through proxy employees, like Health Texas or Physician Services Group, or all these different institutions that the healthcare entities offer or through contracts with the health systems to help manage some of the practice operational things.
Brad: Yeah and I can fact check you right now on the spot. You’re correct that you cannot do surgery via telemedicine, so good catch there.
Michael: Brad’s really smart.
Rick: Not yet. Some of my colleagues with the robots, they’ve dreamed one day of like operating internationally.
Brad: Being in Bora Bora and operating from the beach.
Brad: Well, we’ve covered a lot of ground so far. I guess the last question is, and maybe some of you’ve already talked about, but from your perspective, what is the biggest healthcare compliance challenge that you face as a spine surgeon?
Rick: Well, I think [00:23:00] like many regulatory agencies, people tend to follow the money so the problem is whether you’re a wall street trader and my sister’s a BlackRock executive, people look at where the money goes. So if you’re in a specialty where either you get paid a lot, or your service line is a big revenue draw to the hospital, there’s a lot of healthcare dollars that are affiliated with your name so that’s gonna bring attention. You saw a few years ago, a bunch of guys in town got into trouble with some physician known healthcare facilities and largely many of these areas in healthcare are sort of shades of gray.
Rick: You can have varying legal opinions on what is, and what is not okay. Certainly, with the overhead situation people are always looking for ways to offset practice revenue and expense by bringing in ancillaries or doing things, but we’ve always been cognizant of the fact that look, we’re [00:24:00] doing a lot of things that use healthcare dollars and you don’t want to be in a situation where you’re on your heels trying to defend things. So we personally have stayed away from a lot of ownership and implants or what we perceive as conflicts, not to say those things are necessarily wrong or illegal, and certainly there are ways to do many things, I think compliantly, but we’ve been a little on the conservative side because we do need a lot of institutional support to do scoliosis surgery well, so we’re asking a lot of the hospital systems in terms of service line, resource allocation, and it puts the hospitals in a very bad position if we have conflicts or get into trouble with OIG or somebody like that because it can damage the healthcare systems. It can cause a lot of problems so we’ve tended to sort of be, I would say amongst guys in [00:25:00] town, a bit more conservative with those things and we’ve maybe left some revenue on the table that would’ve been safe to get, but you never know when the winds are gonna change and we like to not be the first guy doing anything and we’re probably not gonna be the last guy. We kind of go with what we are confidence established, it’s been tested, true, and we know, look, if there’s any kind of questions about what we’re doing, either from an insurance company, a governmental agency, CMS, that we are very strong, sound footing. That’s where we really count on you guys to tell us, look, when are we pushing things? What’s really safe? Do we feel good about it? When is, it gives me a little bit of concern?
Brad: Oh, no doubt.
Michael: Yeah and obviously kind of a secondary part of that we see with going to your point of, that it’s a lucrative field where there’s a [00:26:00] lot of opportunity, is that the doctors, the spine surgeons are gonna get presented with a ton of opportunities. Not all of them are gonna be necessarily wise opportunities for them to pursue.
Rick: Yeah. I tell the young guys, it’s a marathon, not a sprint. The goal of medicine is not to go out there and try to stuff every dollar in your pocket, as quick as possible cause ultimately you’re probably not gonna be doing medicine very well. The difference with running a healthcare business and a lot of just consumer facing businesses is the customer’s not always correct, right? Some of the biggest conflicts I’ve had with patients being dissatisfied is me telling ‘em, I don’t think you should have surgery. I have to explain to the patients, look, I mainly get paid to do surgery. We get paid very little to talk to people in clinic.[00:27:00] The healthcare systems certainly like us to do surgery, cause it’s profitable for the hospitals. If I am telling you, I don’t think it’s in your best interest to have surgery, it’s not that I am insulting you. It’s that, I’m trying to be your advocate, you know? That’s something where it can be a challenge because there are always incentives to over utilize healthcare resources, whether it’s personally or institutionally and that’s where specialties in general get a bad rap. So spine surgery, because there’s been a large growth in it, there’s a lot of looking at what are indications? Who’s having surgery? Is this appropriate? So you don’t want to be a guy that’s out there pushing the envelope and operating it on everybody that comes in and that’s also where spine surgery can get a bad rap. If you have very good tight indications for surgery, I think the results are very on par with like hip and knee replacement. If you start operating on stuff, that’s got marginal indications, then that’s when the results are sort of not necessarily as [00:28:00] good. So you have to be sort of conservative and I think in the business and contractual relationships, you have to be mindful of that. So you have to set up things in a way that there’s not a huge, either direct or incentive for you to be overly aggressive because there’s pressures on you. That’s when we’ve aimed to do contracts with either partners or healthcare people, we’ve tried to deemphasize get paid for every like widget you put in or something like that. We want people to emphasize the patients have a good experience. They get better. We’re doing appropriate care. We’re doing good research and we’re keeping a close eye on the results we get.
Michael: That’s amazing. I can’t believe we already blew through our time like we do every time. It was amazing and interesting just like all of our conversations. What we’ll do next is we will say goodbye to our guest. Rick, thank you so much for joining us [00:29:00] today. We’ll go into a commercial and then we’ll come back and do a quick legal wrap up when we get back from commercial.
Brad: Absolutely. Thanks for joining us.
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Brad: Well, welcome back to Legal 123s with ByrdAdatto. I’m your host Brad Adatto. My co-host Michael Byrd still here. Michael, we’re having this season where we’re doing the specialty spotlight and for those watching us on our YouTube channel, you’ll see, the spotlight was three handsome men in blue suits in the blue [00:30:00] podcast room of the Legal 123s with ByrdAdatto. I thought that was pretty well planned since we all were wearing basically the exact same blue suit, which I guess we really didn’t plan that. Did we?
Michael: No, but we were very on brand.
Brad: Yes. Very on brand.
Michael: Okay, cool.
Brad: Well, Michael, there’s a lot to take away. Rick was so kind with so many things and I don’t know if there’s one particular spot that you wanna focus on.
Michael: I wanna kind of pick up where we left off with my last question, which is just the idea that spine is one of those specialties where spine surgeons are gonna get approached by a lot of different people because there’s a lot of money in spine surgery. There are a lot of regulatory issues that go into whether you participate in a deal and maybe you can touch a little bit on the flags that people should look out for.
Brad: Absolutely. Rick brought up a great point. For a spine surgeon, orthopedic surgeon, there’s so [00:31:00] many pieces that you need. You need imaging. You need lab. You need device companies. You need a huge staffing and there are so many different ways in which these outside vendors will come to you and say, hey doc, how about doing this deal with us, where you’re buying this from us? Are you using our imaging center? Some of those things are very legal. We’ve talked about in other episodes, Michael, about anti-kickback and safe and stark with safe harbors and then stark, exceptions. You have to be very careful because what we’ve learned now is even in situations, let’s just pretend Rick had something that we can meet the applicable federal and state laws, there are a lot of times in which the hospital says well, to be on our medical staff, you cannot have any ownership, whether or not it’s legal or illegal. We don’t care. We have our own vendors. You have to use our vendors and you can’t have any relationship with them.
Michael: Avoiding the whole conflict of interests thing he was talking about.
Brad: Exactly and so it’s a contract [00:32:00] restriction so even if we can find a way to legally own it from a federal in-state perspective, you still may have a contract that prohibits it on top that.
Michael: Fascinating. Well, I think we need to wrap up here and I’m gonna type an email very fast to you, challenging you to a pickleball match.
Brad: Excellent. Well, I’ll be out there with my other retired friends and we will crush you. Alright, audience members, we’re still going with the specialty spotlights. Next Wednesday, we have behavioral health spotlight with Brandy Sinclair.
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