Shrinking reimbursement, rising costs and growing administrative burdens are forcing orthopedic and spine surgeons to rethink the traditional playbook of simply seeing more patients to offset financial pressure.
Orthopedic and spine surgeons told Becker’s they are responding by rethinking payer participation, patient access, staffing and care pathways while placing greater emphasis on efficiency and physician-led decision-making.
Question: What have you changed about how you practice because the old way is no longer sustainable?
Editor’s note: Responses have been lightly edited for clarity and length.
Kasra Ahmadinia, MD. Director of Minimally Invasive Spine Surgery at Advanced Orthopedics of Oklahoma (Tulsa): The biggest change has been recognizing that we have to continually find new ways to improve efficiency because the traditional model is becoming increasingly difficult to sustain. We’ve streamlined workflows, leveraged AI and other technologies where appropriate, and remained focused on adopting innovations that improve patient care while meeting patients’ expectations for the latest techniques and treatments.
At the same time, we’ve made access a priority by ensuring patients can typically be seen within days, either by a surgeon or an advanced practice provider. In a market where many patients face waits of several months, improving access has become both a competitive advantage and an important part of delivering high-quality care.
Adam Bruggeman, MD. CEO and Spine Surgeon at Texas Spine Care Center (San Antonio): The old way was take every contract, see every patient, fight denials after the fact, and hope volume covered overhead. Unfortunately, that math doesn’t work anymore. We are actively reviewing contracts and having to make tough decisions. We are working directly with some employers to cut out the middleman, although they still exist in “direct to employer”.
I do anticipate some gating of Medicare and Medicare Advantage patients in the next year with the changes that directly harm independent physicians over hospital-employed physicians. As I was taught while working in hospital administration, if there is no margin, there is no mission. Tough decisions are having to be made every day.
Travis Doering, MD. Orthopedic Hand, Upper Extremity and Peripheral Nerve Surgeon at Upper Extremity ATX (Austin, Texas): I left group practice to start my own solo practice because the old model of adding volume, staff and overhead to keep up with shrinking reimbursement just wasn’t sustainable. Now, I do many hand procedures, like carpal tunnel and trigger finger releases, right in the office under local anesthesia, so patients skip general anesthesia, the facility fee and a trip to the operating room. I run a lean team where AI handles much of our phones, scheduling and documentation, which lets the people we do have spend their time with patients instead of on hold with payers. I also offer bundled pricing, so patients know the full cost of their care up front. Being independent gives me the freedom to build the practice around the patient instead of around the billing system.
Ziya Gokaslan, MD. Chief of Neurosurgery at Rhode Island and The Miriam hospitals and Chair of Neurosurgery at The Warren Alpert Medical School of Brown University (Providence, R.I.): Traditional spine business is built by surgeons performing operations, whereas the new spine business model is built around an integrated system managing patients, outcomes, access, cost and the entire continuum of spine care.
Taif Mukhdomi, MD. Comprehensive Interventional Pain Physician at Pain Zero (Columbus, Ohio): One emerging opportunity is to rethink spine, orthopedics and interventional pain medicine as complementary steps within a single patient-care sequence rather than competing service lines. An integrated approach can incorporate interventional pain medicine before, after or alongside surgery, ensuring the right patient receives the right intervention at the right time, not diverting patients from surgery.
This can preserve surgical capacity for patients most likely to benefit from surgery while appropriately selected patients receive evidence-based interventional treatments. It can also improve access, create clearer workflows, improve provider communication, reduce unnecessary handoffs and allow clinical teams to work at the top of their training.
The broader shift is from a specialty-centric model to a patient-sequence model. Rather than asking, “Is this a surgical patient or a pain patient?” the better question becomes, “Where is this patient in their care journey, and what is the most appropriate next step?”
Emeka Nwodim, MD. Orthopedic and Spine Surgeon at The Centers for Advanced Orthopaedics (Bethesda, Md.): The most significant change has been a shift in mindset, recognizing that the traditional physician and surgeon practice model can no longer be predicated solely on the fundamentals of seeing and treating patients. A successful modern practice must be more comprehensive, encompassing not only clinical excellence but also a deliberate focus on understanding, optimizing and strategically managing every aspect of the business of medicine.
Lali Sekhon, MD. Neurosurgeon and Spine Surgeon at Reno Orthopedic Center: Fee for service is dying. Physicians need to own the whole episode of care from the urgent care to physical therapy to imaging to the surgery center. Without this, groups who depend on just collections and call stipends will wither.
Rajiv Sethi, MD, PhD, Professor of Orthopedic Surgery, Chief of Orthopedic Spine Surgery and Co-Director of the UCSF Spine Center at the University of California, San Francisco: I have been working as attending spinal surgeon for 20 years and have mentored many residents, fellows and young faculty as the landscape for delivering care changes rapidly in the United States. While many American healthcare administrators change jobs routinely moving from job to job around the country and don’t develop decades long relationships within one hospital, most of my trainees work to develop bonds with the communities they serve and want to deliver care in those communities for their entire careers.
It is important to understand that this approach may need to be altered as the economics of healthcare delivery are closely associated with the economic health of the region in which physicians work. In our department at UCSF, we are committed to teaching our residents and fellows more detail about healthcare economics and delivery. As our residents and fellows learn more about healthcare economics and understand the financial health of their future systems and regions, they will be better stewards for themselves, their families and their patients. This will require a more flexible approach that will require attention to changing macro trends.
Johnathon Shaffer, MD. Division Director of Neurosciences at IU Health South Region (Bloomington, Ind.): From early in my career, I have been aware of the economic forces reshaping sports medicine, orthopedics and spine care. Labor, real estate and administrative costs continue to rise faster than reimbursement, while payer requirements shift uncompensated work onto physicians and their teams.
My fellowship showed me what physician-led care can achieve, but also that clinical excellence alone does not guarantee organizational sustainability. In my own practice and leadership roles, I have focused on care-team structure, operational effectiveness and meaningful physician involvement in decision-making.
Efficiency is essential, but we cannot simply work harder or add volume to offset declining reimbursement and growing administrative burdens. A sustainable model emphasizes physician-led care, allows each team member to work at the top of their training and remains disciplined about the true cost of delivering high-quality, accessible care.
Chris Tomaras, MD. Founder and CEO of Axion Spine and Neurosurgery (Alpharetta, Ga.): As an independent practice and having opted out of Medicare almost 20 years ago, we have focused on providing a high level of service to commercial patients. With hospital consolidation increasing, this has become even more challenging. We try to provide each patient with a concierge-type experience — short wait times, prompt communication with providers and personal follow-up by the physicians in the immediate postoperative period. On the cost side, we are adopting AI platforms that will hopefully reduce if not stabilize overhead.
Michael Venezia, DO. Orthopedic Spine Surgeon at Florida Orthopaedic Institute (Tampa, Fla.): The biggest change I’ve made is no longer seeing every patient who comes through the door. Insurers now require physical therapy and other conservative care before I can even order an MRI, so an early visit with a spine surgeon often ends without imaging or a real plan; directing those patients to nonoperative care first frees my schedule for the people who truly need a surgical evaluation, and gets them seen sooner.
Paul Vessa, MD. Orthopedic Spine Surgeon and Medical Director at New Jersey Spine Institute (Bedminster): The practice of orthopedic spine surgery has changed for private practice in many ways over the past 33 years. However, the most significant contribution to change has been the more than 30% decrease in CMS reimbursement since 2000. Early in my career we took on call responsibilities at several hospitals, which required CMS participation. Once that requirement expired we dropped CMS participation and no longer participate in Medicare.
The reduction in reimbursement makes it nearly impossible to participate in a program that continues to diminish its payments, especially in light of the increase in private practice expenses over the past 30 years. Presently, it is outrageous that after all the training and experience we bring to the marketplace a standard laminotomy / discectomy in the lumbar spine in Medicare pays less than what I presently pay my landscaper. My concern going forward is that if this trend is not reversed healthcare accessibility will become increasingly limited to family, friends and the wealthy. Despite the promises of the Affordable Care Act, the middle and lower classes have been dramatically impacted by a healthcare system that has rewarded the health insurance industry over the health of its citizens.
David Weiner, MD. Assistant Professor of Orthopedic Surgery at MedStar Health (Columbia, Md.): The biggest change has been moving beyond the assumption that the
answer to every pressure is to see more patients or ask the existing team to do more. We have become more intentional about how patients enter the practice, whether they have the workup needed for a meaningful surgical consultation and how we connect them with the appropriate surgical or nonoperative care. Access has to include what happens after an appointment is scheduled: how quickly we can establish a plan and help the patient move forward.
That has also meant rethinking how we distribute clinical and administrative responsibilities, giving staff clearer ownership of different parts of the care process, and preserving physician time for complex decisions and patient conversations. Reimbursement pressure and staffing constraints make efficiency necessary, but a practice can look productive on paper while patients still encounter delays and the team stretches beyond its capacity. The focus must be shifted toward making sure growth is supported by the people and processes needed to
deliver timely, thoughtful care.
Aqib Zehri, MD. Neurosurgeon at The Oregon Clinic (Portland): One change I’ve made in my practice is placing much greater emphasis on long term follow up after spinal fusion. I think we need to follow patients beyond the initial postoperative period and actually determine whether a durable fusion has been achieved. I typically follow my fusion patients for one to two years, or until fusion is confirmed. This level of longitudinal follow up was not emphasized during my training, but I believe it adds significant value by allowing us to better understand our outcomes and continually improve how we care for patients.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Practice patterns and their adjustments ordinarily occur as both exposure and experience are accumulated over time. The shifting scenarios of aggressive, multilevel spinal fusions and its expense are no longer contemporary, yet neurodegenerative disease is no less frequent nor diagnosed in society. Healthcare delivery remains secular as for-profit dispensaries remain exclusive, and larger institutions continue to administer to the folks. Albeit the conservative approach and its mentality of care is more prevalent nationwide, but this compensatory recoil was secondary to decades of subtleties, and suppositions are currently replaced with symptom-based indications and radiologic confirmation as the acceptable precedence.
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