It is no secret for physicians that a number of surgical procedures, especially in the musculoskeletal space, are moving to the outpatient setting.
By 2028, 88% of spinal decompressions and laminectomies and 67% of cervical spinal fusions are expected to be performed in the outpatient setting.
In addition, more orthopedic CMS codes are being added to the ASC approved procedures list, and the costs of operations at ASCs are typically much lower for patients and payers.
That is why several major orthopedic practices are homing in on outpatient care expansion. In 2025 alone, several major health systems, including Louisiana Orthopaedic Specialists in Lafayette and DISC Surgery Centers in Newport Beach, Calif., have announced plans for new orthopedic ASCs.
OrthoCarolina, a major academic orthopedic practice treating more than 1 million patients annually in North Carolina and South Carolina, is also carefully following this trend.
The Charlotte, N.C.-based practice, led by CEO and orthopedic spine surgeon Leo Spector, MD, employs more than 300 practitioners in the area.
In the last year, the practice made several major pivots, deciding to sell its physical therapy and MRI facilities to double down on outpatient care.
Dr. Spector spoke with Becker’s about why the practice plans to remain “bullish” on ASCs, innovating alongside the changing orthopedic care landscape.
Question: What is OrthoCarolina’s practice strategy this year?
Dr. Leo Spector: ASCs are unique in the Carolinas because while certificate-of-need reforms may have a negative impact on the MRI business, it has a very positive impact for surgery centers because now that South Carolina has fully repealed CON and North Carolina is about to at the end of this year, it creates the opportunity for us as a private practice to own our own ASCs. We estimate that 70% of our surgeries here in the musculoskeletal space can be done in the ASC. We feel that really aligns with our core mission and our values, which is, we are here to make lives better. We want to improve the cost of care for our patients throughout the Carolinas. If we can move patients appropriately from inpatient to outpatient and move from HOPDs to ASCs, we can lower the cost of care by our estimates; if we were to move the full 70% of cases, we would need far more capacity than we currently have. The opportunity for us to invest both the financial and human resources into growing the ASCs was really a decision we made. We look back at therapy and MRI as being service lines that are not as core to what we do. So to have the opportunity to invest and to grow outpatient care will be a win to not only our patients but our practitioners.
Q: Do you believe the future of orthopedic care rests in ASCs?
LS: We have always been bullish on ASCs. We have seen a huge uptick in use of ASCs post-COVID. There was a lot of hesitancy from some of the practitioners and some of the patients. We are all creatures of habit, and it’s comfortable to go to a hospital and continue doing what we are doing. But getting patients and practitioners to adopt ASCs post-COVID really opened that up. When hospitals were having to take care of all of those sick patients and could not do elective surgeries, ASCs were open and able to continue doing those. As much as orthopedics is elective, when you are hurting, you still want that taken care of. It created a lot of options for both practitioners and patients. So coming out of COVID we have seen a nice uptick in the utilization of our ASCs. Our current ASC ownership structure is a result of the CON laws that existed in North Carolina.
We have multiple ASCs, but the ownership structure is different for each one. They are partnerships with different hospital systems, sometimes different management companies, and it’s typically done with the individual shareholders. So there is not a cohesive OrthoCarolina strategy and that is because of the nature of what we had to deal with in the past. We had to set up each ASC based upon wherever we could create a partnership with the hospital system and or management company. Post-certificate of need, that changes. We can really take control of ASCs and move them 100% into OrthoCarolina ownership. It does not mean we may not want to continue partnering with hospital systems, and or management companies, if it makes sense, but it allows us to take a patchwork of ASCs and create a comprehensive OrthoCarolina ASC strategy under OC ownership. We think that will be a better way to bring uniformity to what we are doing.
Part of that vision is also to concentrate services. Some of the stuff that you do in an ASC, especially hips and spine, sometimes take 23-hour observation capability, whereas stuff that hand, foot, ankle and sports does doesn’t require that. So we may have one center that’s focused on hip and spine and make that a larger center that can really specialize, which will provide a better experience for patients and practitioners.
We know it will take a lot of work to get from here to there. A lot of things will have to be done in regards to our legacy ASCs, and so again we look at the PT and MRI and we only have so much bandwidth. Our team needs to be able to focus on certain things. We really felt this was a deep opportunity to divest of our two ancillaries that were not a part of our core and really double down on our core business.
Q: Is there anything else you want to expand on?
LS: For me, in this role, watching what has occurred over the past five to 10 years in healthcare, we’ve seen a lot of changes and talk about rising costs of care. We’ve seen value-based care taking hold in the musculoskeletal space, and we are seeing bundles start to take hold as well as direct to employer contracts. It’s a really interesting time in the musculoskeletal space. We’ve seen activity in private equity that has occurred, both successes and non-successes, but there’s a lot of change, and for me I think that creates a lot of opportunity.
We as an organization had two choices. One was to keep doing what we were doing and hope that what got us here will get us there. In a changing environment, that’s not the best strategy. We looked at all of the changes that were occurring and decided to make that pivot in regards to that investment and divestment. We are doing quite well, but if we want to be as successful as we have been the last two decades, we have to make some strategic moves to change alongside healthcare. At the end of the day, it’s about investing to deliver more value to our patients. Expanding access to our whole community. Getting rid of those service lines and investing in ASCs was a great way to bring that value to our patients.
