Private equity has become a major force in physician-practice consolidation, and orthopedics and spine surgery remain among its most attractive targets. But a decade in, evidence on private equity’s effects is mixed, and its long-term legacy may depend more on governance than deal volume, according to an article in the summer 2026 issue of Vertebral Columns.
Eight things to know:
- PE built its position in orthopedics in three phases. Early interest from 2014 to 2017 stayed largely local, with a review of orthopedic deals from 2010 to 2019 identifying 68 transactions, only five of them PE-backed. A platform-building phase from 2017 to 2021 saw 11 PE-backed orthopedic platforms launch between 2019 and 2021. Since 2022, activity has shifted toward secondary recapitalizations, bolt-on acquisitions and operational integration rather than new platform formation.
- Orthopedics and spine remain attractive to PE. because of high procedural volume, ancillary revenue opportunities and continued fragmentation of private practice. More than half of orthopedic surgeons still reported working in private practice models in 2024, even as physician ownership declined nationally.
- Outpatient migration has raised the financial value of ASC ownership. Lumbar fusion utilization has risen markedly over the past two decades, and spine volume has increasingly shifted to ASCs, where facility costs run below hospital outpatient departments. Ancillary services including imaging, physical therapy, pain management and durable medical equipment let vertically integrated platforms keep referrals internal and diversify revenue.
- Federal scrutiny has intensified. In 2024, the Federal Trade Commission, the Department of Justice and HHS launched a cross-government inquiry into healthcare consolidation and PE-backed roll-up strategies. In January 2025, the FTC reached a settlement tied to a PE roll-up in anesthesiology. The authors linked the heightened oversight to concerns about pricing power, referral control and competition.
- Current evidence is mixed, though cost trends are more consistent than quality trends. Systematic reviews have generally associated PE ownership with increased spending and utilization, while evidence of improved quality outcomes remains limited. Studies have also found higher physician turnover and repeated secondary buyouts over short timeframes, raising questions about organizational stability and retention.
- Spine surgery sits at a particular pressure point. It pairs high procedural reimbursement with ancillary opportunities, but inflation-adjusted Medicare reimbursement for common spine procedures has declined over the past two decades even as utilization has risen. That squeeze increases pressure to capture facility and ancillary revenue, and the authors flagged concern that financial incentives could influence site-of-service or procedural-expansion decisions.
- Surgeon attitudes remain divided. Some view PE partnerships as practical solutions for succession planning, liquidity and administrative support, while others cite loss of autonomy, pressure to meet productivity targets and reduced influence over practice direction. Those concerns may weigh most heavily on younger surgeons as partnership tracks give way to employment-based structures.
- PE “should not be viewed as inherently beneficial or harmful,” the article concluded. Rather, its outcomes vary based on governance, debt structure, physician alignment and operational priorities. The authors added that PE’s long-term legacy in musculoskeletal care will likely depend less on acquisition activity itself and more on whether platforms prioritize durable clinical systems or short-term enterprise valuation.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
