Peter Derman, MD, did not leave Texas Back Institute because he wanted distance from the institution. He is clear about that.
After nearly eight years at the Plano-based spine group, where he served as a partner and executive committee member, Dr. Derman still speaks highly of the practice. He remains closely aligned with Texas Back Institute, continues to collaborate on research and teaching and still receives referrals from former partners.
The decision was about a different problem. His practice had become increasingly focused on minimally invasive, non-fusion spine surgery, particularly endoscopic decompression. Patients were seeking those procedures and surgeons were increasingly interested in learning them. But the reimbursement system often placed far greater value on larger fusion and deformity operations than on smaller outpatient procedures.
“The incentives are, in my opinion, misaligned,” Dr. Derman told Becker’s.
His solution: On July 1, he opened an independent, private-pay solo practice in Dallas dedicated to minimally invasive and endoscopic spine surgery.
The math stopped working
Dr. Derman is careful not to frame fusion surgery as the problem.
“There are definitely scenarios where those surgeries are necessary and can be wonderfully helpful to patients,” he said. But he also believes many patients can benefit from smaller procedures before they ever need a larger operation. The challenge is those smaller procedures can be harder to sustain financially under the traditional reimbursement model.
Over time, as endoscopic surgery became a larger share of Dr. Derman’s operations, payment rates declined while overhead continued rising. Rent, staff, benefits and other practice costs moved in one direction; reimbursement moved in another.
Eventually, the options became clear. Do more fusions, see more patients or leave the insurance model. The first option did not fit the practice he wanted to build. The second had already begun to change how people in medicine felt.
“It becomes like this conveyor belt that goes faster and faster and faster,” Dr. Derman said. “It really takes a lot of the joy and personalization out of medicine.”
That was the obstacle he could not get past.
“That’s just not why I went into medicine,” he said. “I went into medicine because I like to talk to people, and I like to empathize with them and I like to celebrate their success with them when they’re done.”
Removing the ‘wall’
Dr. Derman’s new practice is private pay for his services. He is not contracted with commercial insurers or Medicare for clinic visits or surgeon fees. Patients can still use insurance for other parts of care, including facility fees, anesthesia, imaging, physical therapy and other services.
For Dr. Derman, the change restores a relationship he believes has become distorted.
“I offer endoscopic spine surgery. The patient wants endoscopic spine surgery, and the insurance company says no,” he said. “There’s a wall in between us.”
The private-pay model removes that barrier. It also makes pricing clearer. Patients are told up front what his services cost before moving forward.
“There are no surprises,” he said.
A practice built around speed
The new practice is designed for a specific kind of spine patient. Many have acute radiculopathy or painful disc herniations. Dr. Derman calls them “hot discs.”
“They can’t wait six weeks to be seen,” he said. “They’re in horrible pain.”
At his previous practice, patients often faced long waitlists. At his new one, success is not measured by how long patients are willing to wait. It is measured by how quickly they can get answers.
One of the main tools in this effort is an asynchronous MRI review. Patients submit imaging and clinical information through a streamlined intake process. Dr. Derman reviews the material, records a video explaining what he sees, connects the imaging to the patient’s symptoms and outlines potential options. The video is then sent directly to the patient.
The model serves two purposes: It accelerates access, and it gives patients something they can revisit.
“They can refer back to it, they can watch it with their family, they can take notes,” he said. By the time patients meet with him virtually or in person, they are often less overwhelmed and more prepared. “They come with very good questions.”
The business of making care feel better
Dr. Derman earned an MBA while in medical school, and the degree has become newly relevant as he builds the practice.
In a solo practice, the surgeon becomes responsible for nearly everything: human resources, marketing, finance, IT, compliance, scheduling, credentialing and patient communication. It has forced him to rethink the patient journey from the ground up. A call should not turn into a maze. A surgical candidate should not wait weeks for guidance. A patient should not be surprised by opaque billing. For Dr. Derman, the business of medicine is not separate from care. It determines how care feels.
AI has helped make that possible. He is not using it to make clinical decisions but to support the operational work around the practice, from website development and search engine optimization to administrative questions, documentation, scheduling and insurance workflows.
“AI has been unbelievably helpful in this process,” he said. “It has basically leveled the playing field and allowed solo practices like this to be a real attainable thing.”
That may be one of the broader implications of his move. AI is not only changing diagnosis, documentation and surgical planning. It may also change what kinds of practices physicians can build.
Why endoscopy fits
Endoscopic spine surgery is particularly suited to the model Dr. Derman is building. The procedures are minimally invasive, outpatient and commonly easier to travel for than larger reconstructive operations. Patients can fly to Dallas, undergo surgery and return home the same next day, far more quickly than they could after a major fusion or deformity case.
Dallas has built-in advantages as well. With two major airports and a central location, patients from either coast can reach him relatively easily.
That matters because many of his patients come from across the U.S. or outside the country seeking endoscopic options they have struggled to access elsewhere. The practice is built around that reality: remote imaging review, fast triage, transparent pricing and efficient surgical scheduling.
The burnout question
Dr. Derman was unsure how colleagues would react when he began telling them about the move. He worried some might accuse him of selling out or abandoning the traditional system. Instead, many were curious. Some were enthusiastic. Others told him they had already shifted toward concierge or cash-pay models and found it transformative.
“A lot of people were super interested in learning more about this,” he said. “They are so frustrated and burned out.”
For Dr. Derman, the new practice is not only a response to reimbursement. It is a reaction to a professional life that had become harder to sustain. Soon after opening the practice, he had breakfast with his children on a weekday morning.
“That hasn’t happened in years,” he said.
The problem spine surgeons are actually trying to solve
Dr. Derman also reflected on the kinds of issues surgeons discuss at meetings. Clinical conferences often revisit familiar questions.
Those discussions matter, he said, but they are not the only problems surgeons are trying to solve.
“The real struggle that spine surgeons are having is not what to do with an L4-5 spondylolisthesis, or what to do with a disc herniation,” Dr. Derman said. “It’s how to structure their practices and their lives so that they can lead a meaningful life and also provide patients with the care that they deserve.”
That may be the clearest explanation for his decision. Dr. Derman did not leave a major spine group because he wanted to step away from medicine. He opened a new practice because he wanted to build a version of medicine that felt more aligned with why he entered the field in the first place.
For decades, physicians have been told the answer to financial pressure is scale.
Dr. Derman is testing a different model. Smaller. Faster. More transparent. More specialized. And built around a relationship he believes the system has made too hard to protect: the one between surgeon and patient.
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.
