Spine surgery is reaching a stage where structural redesign is no longer optional. The pressures outlined in part 1 of this series are converging in ways that make the traditional practice model increasingly unsustainable. Yet these pressures also create a strategic opening to build a scalable, modern infrastructure that restores surgeon autonomy and delivers predictable, high‑value care. The specialist-led care model offers that path, but only if it is built intentionally and with the infrastructure to enable the model to operate broadly.
Scaling this model begins with acknowledging a simple truth: spine care is complex, variable and resource‑intensive. Most spine patients begin their care journey outside the specialist’s view with primary care clinicians initiating conservative treatment, ordering imaging and managing symptoms before a surgeon ever evaluates the patient. This creates fragmentation and delays the coordinated, specialist‑led pathway that can produce better outcomes.
The International Society for the Advancement of Spine Surgery recently noted in their commentary on the 2027 physician fee schedule proposed rule (CMS-1848-P), that modern payment systems “measure discrete procedural events rather than the physician’s responsibility for the complete episode of care.” That gap is exactly why scalable infrastructure must support every phase of the spine care continuum – from initial evaluation through postoperative recovery – and why a model that recognizes and reimburses the surgeon’s oversight, administrative work and clinical leadership is essential to producing high‑quality outcomes and reducing surgeon burnout. Practices exploring this shift often ask what comes first, and it starts with designing triage pathways.
The first building block is standardized, evidence-based triage and diagnostic pathways designed to make the patient journey more efficient from the point of entry. Variation in early evaluation can lead to unnecessary imaging, duplicative consultations, inconsistent treatment plans and delays in reaching the appropriate specialist. In a specialist-led care model, spine surgeons work alongside multidisciplinary teams to design and continually refine pathways toward the appropriate level of care. These pathways should begin with evidence-based algorithms, increasingly informed by machine-learning models and longitudinal clinical datasets, that identify patients most likely to benefit from conservative care while simultaneously recognizing those with clinical features that warrant expedited specialist or surgical evaluation. The objective is not to accelerate patients towards surgery, but to accelerate each patient toward the appropriate care plan – maintaining the conservative clinical approach while reducing unnecessary delays for patients who ultimately would benefit from specialist intervention.
Standardization, where clinically appropriate, can therefore serve several complementary goals: reducing avoidable utilization, improving access, shortening the time to appropriate treatment and creating a foundation for value‑based contracting. ISASS has emphasized that meaningful variation exists in spine care, and not all of it reflects legitimate differences in patient complexity. Surgeon-designed standardized pathways can help distinguish clinically necessary variation from unnecessary variation, while preserving individualized decision-making when patient circumstances require it. Importantly, designing, implementing, evaluating and continually refining these pathways requires substantial time, clinical leadership and oversight that are largely uncompensated under traditional payment models. A core premise of a specialist-led care model is that surgeons should be compensated for this responsibility as the value they create extends across the entire patient journey, rather than beginning and ending with the operative episode.
Site‑of‑service optimization is the next core component in a specialist-led care model and illustrates how physician leadership can translate into system-level value. Safe migration of appropriate spine procedures to ASCs require more than simply relocating an operation. It depends on institution specific patient-selection criteria, standardized preoperative optimization, comprehensive patient and staff education, clearly defined perioperative pathways, and comprehensive clinical and operational infrastructure necessary to safely perform increasingly complex procedures in the outpatient. Surgeons are uniquely positioned to lead a team in determining which patients and procedures can appropriately migrate to lower-cost sites of care and to establish the clinical safeguards necessary to do so. Specialist-led care recognizes this programmatic oversight as part of the value surgeons provide, rather than treating the surgeon’s contribution solely as the technical performance of an operation. This distinction is particular important during policy discussion as traditional site-of-service savings emphasize facility efficiency without fully accounting for the physician leadership required to achieve those efficiencies safely
Multidisciplinary care teams form the ecosystem around a successful specialist-led care model. Advanced practice providers, physical therapists, behavioral health specialists, dieticians, care managers, and pain management clinicians work together to reduce fragmentation and move patients efficiently toward the most appropriate intervention. For patients likely to benefit from nonoperative treatment, this structure facilitates earlier and more coordinated conservative care. For patients with pathology or clinical features suggesting a need for surgical evaluation, the same pathway can reduce unnecessary intermediate steps and expedite access to the appropriate specialist. This coordinated model also supports site-of-service optimization by improving preoperative selection and optimization, standardizing postoperative recovery, and providing the longitudinal infrastructure necessary to safely manage patients outside the traditional hospital setting.
Digital patient engagement is another pillar of scalable specialist-led care. App‑based perioperative education, postoperative communication tools and digital PRO collection can improve preparedness, reduce emergency department utilization and strengthen patient satisfaction. These tools also create the data backbone required for specialist-led care. ISASS has urged CMS to increase transparency in valuation methodology, noting that greater visibility strengthens public trust. Digital platforms can support transparency by consistently capturing outcomes that matter — pain, function, disability and quality of life and by using those data to inform appropriate reimbursement.
Supply chain optimization is equally important to this new model. Implant and biologic selection have an outsized impact on ASC viability, and surgeon‑led contracting can reduce variation, improve bargaining power and free resources for enabling technologies. Standardizing vendors, negotiating volume‑based pricing, and adopting evidence‑supported systems allow practices to reinvest savings into robotics, navigation and other technologies that enhance precision and patient outcomes. ISASS has described reimbursement instability as creating “innovation friction,” a structural resistance that slows adoption of validated technologies. A surgeon‑led supply chain strategy can counteract that friction.
Scaling specialist-led care also requires collaborative surgeon networks, because no single practice can build or sustain all of the operational and technological infrastructure necessary to support and expand the model. Networks create shared infrastructure for triage pathways, data platforms, supply chain management, outcomes measurement and payer contracting. They can strengthen negotiation leverage, support consistent patient-related outcome date collection, and create a unified clinical identity that payers and employers can recognize.
Importantly, systematic PRO collection, clinical integration and collection monitoring is neither administratively neutral nor costless. Meaningful implementation requires technology infrastructure, personnel, patient engagement, data aggregation and maintenance, longitudinal follow-up and physician oversight to ensure that the information collected is clinically relevant and appropriately interpreted. Each of these activities requires time and financial resources, yet under current reimbursement structures they are generally treated as implicit components of a physician responsibility, rather than a separately recognized source of clinical value. CMS-mandated PRO collection in total joint arthroplasty demonstrates the broader policy movement toward incorporating longitudinal PRO collection into quality assessment, and similar requirements may ultimately extend to spine care. If these expectations continue to expand without corresponding changes in reimbursement – in contrast to the current annual erosion of surgeon professional fees – surgeons and their practices will assume an increasing administrative and financial burden that is not adequately reflected in procedural reimbursement or global-period payment. Collaborative surgeon networks provide an opportunity to distribute this infrastructure across practices while specialist-led care provides a framework for recognizing and compensating the physician leadership required to develop, oversee and act upon these increasingly important measures of quality.
Finally, scalable infrastructure positions practices for direct‑to‑employer contracting. Employers increasingly seek predictable, high‑value musculoskeletal care that reduces disability and improves return‑to‑work timelines. When surgeons lead pathways, optimize site‑of‑service decisions and measure outcomes through validated PROs, they can deliver bundled care that meets employer needs while preserving clinical autonomy and appropriately compensating them for the administrative work involved in managing and refining clinical and operational pathways. Direct‑to‑employer contracting and ASC site‑of‑service bundles are a natural extension of specialist-led care and a critical component of future growth.
The infrastructure required to scale specialist-led care is achievable, and already emerging across forward‑thinking practices. Part 3 in this series will examine the core components required to enact specialist-led care, and why the time to act is now.
Dr. Phillips is an orthopedic spine surgeon at Midwest Orthopaedics at Rush University in Chicago; Dr. Moss is professor and chair of the department of orthopaedic surgery at the University of Connecticut in Farmington; Dr. Massel is a spine surgeon in the department of orthopaedics at Endeavor Health in Skokie, Ill.; Ms. Jacoby is CEO of Denver-based healthcare consulting firm VectorMedicalGroup; and Ms. Reid is founder and operator of Marney Reid Consulting in Cornelius, N.C.
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.
