How spine surgery competition is evolving by market: New York, Arizona, California and more

Practice Management

Big players expanding into new territories, the expansion of telemedicine and patients increasingly demanding more convenient access to care are some of the major trends affecting competition among spine practices.

Eight spine surgeons from independent practices and health systems across seven states, including New York, Arizona and California, discuss how competition is changing in their market and what they expect for the future. 

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: What’s the most controversial trend in spine surgery today?

Please send responses to Alan Condon at by 5 p.m. CDT Wednesday, Nov. 2

Editor's note: Responses were lightly edited for clarity and length.

Question: How has competition evolved in your market over the last three years? What are you expecting in the future?

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Connecticut is a state with several large cities, but it is also largely suburban and nestled between the metropolises of New York City and Boston. Many patients in areas like Fairfield County, Conn., often sought care in New York City. The pandemic really changed that, as many patients have sought out more local care rather than traveling out of state. The importance of local care has stood firm even as we emerge from the heights of the pandemic. Excellent local care is about providing the right care to every patient every time. This has become the mantra of our Hartford Healthcare Spine and Wellness Center in Westport, Conn., which has seen a 300 percent increase in volume over the past two years. 

The other important trend we have seen is the expansion of telemedicine, and the expansion of the radius from which we draw patients because of it. Many patients are able to schedule first-time visits virtually to determine if they need surgery. We are able to collect a thorough history and basic examination as well as review imaging very effectively. Because most providers can only do in-state televisits as an initial visit, many patients in Connecticut have opted to see providers this way rather than travel long distances. This has changed competition to a statewide process.

Ali Araghi, DO. The CORE Institute (Phoenix): Over the last several years, we have seen the competitive landscape change in several ways. Phoenix has grown exponentially in recent years, and with that has come a rise in competition for patients, who are now more consumer-centric and looking for providers based on convenience, access and quality. Fortunately, over the last 15 years, we have established a reputation throughout Phoenix as providing high-quality care, easy access and superior outcomes. Patients from around the country are coming to us based on this reputation and Ranking Arizona has recognized us as the  No. 1 orthopedic practice for 10 years in a row, which is a tremendous honor. 

From the payer and health system perspective, the most significant change has been the push for physicians to assume more financial risk on outcomes. As a HOPCo-managed company, we have been at the forefront of value-based care for over a decade and have successfully navigated the shift to more value-based models. Where many practices see hospitals and payers as competitors, our approach has been to align these stakeholders and create more advanced models, such as clinically integrated networks and true population health programs.  These programs are more sustainable and have been proven to bend the cost curve for musculoskeletal care while simultaneously improving patient outcomes. This model has been successful not only here in Phoenix but on a national scale as well, as HOPCo has partnered with musculoskeletal practices and health system service lines across the country and replicated the success we have seen in Phoenix. 

Overall, I see more competition on the horizon. The path to success is getting better at managing your risk by improving outcomes; otherwise, there will be financial accountability for complications and inefficiencies.

Issada Thongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): The competition is high. I am focusing on what I do best, which is endoscopic and non-fusion surgery. I am not competing to get deformity patients and other complex patients. I feel that direct communication with the consumer via social media platforms is the key. I expect there will be less independent practice in the future as it is very difficult to compete with the big groups or healthcare systems unless you find your niche.

Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): In spine surgery, the competition went through a restructuring over the last three years. The restructuring now revolves around mergers and acquisitions of the different practices. Practice organizations continue to change as healthcare systems buy smaller practices. As private equity buys a practice, practices are growing larger and have an advantage with payers. Competition is no longer the neighboring practices down the street, instead practices are competing with large healthcare systems that have MSOs and private equity-backed firms that own their own MRI scans, service centers and more. Smaller offices are competing with corporate entities instead of other spine surgeons, which change the dynamic of the competition.

I believe this trend will continue in the future as markets are going to merge and get tighter. I worry that healthcare will become a vertical monopoly as one organization owns the surgery center, the physician, the practice, the MRI and more.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: There has been a flood of fresh graduates employed by both academic and "nonprofit" entities in our market. We have many experienced and very savvy private practitioners still and it certainly has become competitive. The neat thing about our market is that you really have to bring it, surgically and outcome wise. So really, the high level of competition allows for skill differentiation and niche-building by those that can withstand the large number of surgeons in the market. For the most part, surgeons are operating on indication. Patients have a lot of choices, so it helps to have a diverse number of surgeons that allows for healthy competition between surgeons for cases. I think at the end, the patients definitely have a wide variety of choices, skill sets and surgeon disposition. I expect this will continue to be the case. My hope is that our community remains an exemplar of how to operate on indication and in the best interest of our patients. In the end, it helps those we treat, and makes us better surgically.  

Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): Competition has evolved on a large-scale health system level. Patients are more locked into systems and that has reduced competition because patients are not able to get second opinions. In the past Medicare patients had many options but now with Medicare Advantage plans they are more set in their systems and less able to choose other providers.

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): In the last three years, competition in the marketplace of spine surgery has prompted major shifts. Firstly, highly competitive individuals are seeking world-class fellowships with prestigious institutions and are being trained directly by masterful leaders in the field. Such fellowships are teaching operative techniques and surgical approaches that enhance the capabilities of those who attend. Those surgeons are very marketable to the public and are very respected by their peers as well as referral sources. Therefore, competition has evolved to become heightened in skills and usage of technology. Secondly, it can be expected in the future that even more neurosurgeons seek these fellowships to compete with others that have enhanced training.

Chester Donnally, MD. Texas Spine Consultants (Addison): I think the main change is, fortunately, patients are becoming more connected and more informed about their surgeons. There are more avenues to learn about providers and it helps primary care physicians and patients see who they should pick for spine surgery.

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