For years, hospitals and health systems have grown larger. Now, some orthopedic surgeons are trying a different strategy. They’re getting bigger so they can stay independent.
That is the thinking behind OrthoTexas, a newly unified organization that will bring together five orthopedic and spine practices across the Dallas-Fort Worth region under a single brand later this year. The combined group will include more than 70 physicians across 22 locations, making it one of the largest independent musculoskeletal practices in Texas.
For Michael Briseño, MD, chairman of OrthoTexas and a spine surgeon at Grapevine-based North Texas Orthopedics & Spine Center, the move is about more than scale. It is about preserving physician autonomy in a healthcare system that has increasingly tilted toward consolidation.
“In Texas, especially in private practice, we’ve been historically very fractured,” Dr. Briseño told Becker’s. “A lot of small groups have worked in their silos for decades and done well, but that has diluted our voice.”
That trend extends far beyond orthopedics. Just over a decade ago, most physicians still practiced independently. Today, more than half are employed by hospitals or health systems. As consolidation has accelerated, Dr. Briseño argues that physicians have lost influence over decisions that affect both their practices and their patients.
“What that does is drive up costs, drive up vertical integration and lessen physicians’ power and autonomy to make decisions for their patients,” he said.
The extinction of independent practice?
The idea behind OrthoTexas emerged from a question many physician groups are asking. How do independent practices compete with increasingly large health systems without eventually being absorbed by them?
For Dr. Briseño, the answer is scale. The participating groups had each spent years fielding recruitment efforts from hospitals and health systems. “We were recruited and poached by health systems for years,” he said. “We put them off and put them off because we didn’t want to go into that type of environment.”
At the same time, he said, remaining small created its own disadvantages. Negotiating with payers became more difficult. Administrative costs continued to rise. Technology investments became increasingly expensive. Most importantly, independent physicians often found themselves absent from policy discussions that shape healthcare reimbursement and regulation.
“When you’re a one-person group, a two-person group or even a five-person group, you’re lost and you’re not going to get heard,” Dr. Briseño said. The result is what he sees as one of the biggest misconceptions among physicians.
“I think physicians want to hold on to the mantra of, ‘I went to medical school to be a doctor,'” he said. “And I think that’s a mistake.”
Physicians, he argues, cannot afford to disengage from the business and policy forces shaping healthcare. “If we don’t control or have influence on our industry, then we lose influence,” he said. “We have to be our patients’ best advocate, which means we have to get engaged with those other parts of running a medical practice.”
The private equity question
One of the more complicated aspects of the OrthoTexas model is that the participating practices are partnered with United Musculoskeletal Partners, one of the nation’s largest orthopedic management organizations.
For some physicians, private equity involvement raises concerns about whether independence can truly be preserved. Dr. Briseño believes the distinction comes down to governance. Every physician group joining OrthoTexas, he said, was selected because of a shared commitment to physician-led decision-making and clinical autonomy.
“We prioritize clinical quality and clinical autonomy,” he said. The Texas organization is governed through a physician-led clinical governance board composed exclusively of physicians from the participating practices. According to Dr. Briseño, decisions involving operations, staffing and clinical strategy remain in physician hands.
“There is no MBA telling us what to do or mandating what to do,” he said. “It is physicians who are in the weeds with our staff every single day.” That structure, he argues, makes the model fundamentally different from traditional employment arrangements. “We actually think it accentuates private practice,” he said.
The policy fight ahead
While scale may help independent groups compete operationally, Dr. Briseño believes policy remains the larger challenge. He points to three issues in particular: Medicare reimbursement, site-neutral payment reform and the federal 340B drug pricing program.
Of the three, site-neutral payment reform may be the most consequential for orthopedic practices. Currently, hospitals can receive substantially higher reimbursement than independent physicians for performing the same services in hospital outpatient departments.
According to Dr. Briseño, that creates a powerful incentive for hospitals to acquire physician practices and expand their employed networks. “HOPDs can get paid five or six times more for the same procedure,” he said. The downstream effects, he argues, extend beyond physician employment.
“If we just did site-neutral reform over 10 years, that’s roughly $200 billion in savings for the country,” he said. The issue has become a central focus for organizations such as the American Independent Medical Practice Association, a national advocacy group representing independent physicians.
Dr. Briseño believes many lawmakers understand the concerns once they hear them. The challenge is making sure independent physicians have a seat at the table.
“The healthcare system lobbyists are there every day,” he said. “We’re there once or twice a year.”
A different vision for consolidation
Ironically, the creation of OrthoTexas represents a form of consolidation. But Dr. Briseño views it as fundamentally different from the hospital acquisitions that have reshaped much of healthcare.
The goal is not to centralize control. The goal is to preserve it. As the organization continues to grow, he says leadership is being deliberate about who joins. “We were very selective about who is joining this group and who we want to partner with going forward,” he said.
The criteria go beyond financial performance. The group is looking for physicians who believe in independent practice, prioritize high-quality care and remain deeply connected to the communities they serve. “If you pick the wrong partner, it can blow up in your face,” Dr. Briseño said. The process that created OrthoTexas took years. The practices first partnered with UMP in 2022, and leaders spent more than 18 months planning the unification before announcing it publicly.
“We didn’t rush it,” he said. “We went really slow, very deliberate.”
That approach reflected what Dr. Briseño sees as the central challenge facing independent medicine. Every decision matters. Every governance structure matters. Every partnership matters.
“If you give up the ability to make those decisions and have someone else make them for you,” he said, “that starts a slippery slope where you begin giving up more and more of your autonomy.”
For now, OrthoTexas is betting that independence and scale do not have to be opposing ideas. In an industry increasingly defined by consolidation, the group is trying to prove they can be complementary.
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