Investments 5 spine surgeons are prioritizing in 2024


Spine surgeons are thinking strategically about where they invest in their practices as well as outside of work. 

Five spine surgeons discussed considerations among themselves and their colleagues.

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 question: As healthcare changes, what pivots are you making to grow patient volume and referrals?

Please send responses to Carly Behm at by 5 p.m. CST Wednesday, Feb. 21.

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

Question: What capital purchases or investments will you make?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Currently, we were looking to make some new equipment to increase the services we offer. The return on investment of any capital purchase is hard to pin down, as reimbursements from insurers are never a sure thing. One may consider just having pay per service, but that quickly becomes a difficult proposition for most patients. Also, one wants to stay compliant with state and federal laws to make sure one stays out of the pokey.  

Jason Liauw, MD. Hoag Orthopedic Institute (Laguna Hills, Calif.): At the hospitals we operate at, we already have three O-arms — a Pulse System with Siemens 3D C-arm, a Medtronic Mazor Robot, a Stryker Mako Robot, a Globus Excelsius Robot, a GE 3D C-arm, the new Spineart E-Cential Robot and the Augmedics system. Having tried a lot of these technologies, I believe there is a lot of overlap and future capital purchases will focus on systems that have multi-system relevance and durability over the upcoming decades. With regards to robots we hope to bring in robots that have relevance for both spine and general orthopedics simultaneously. For imaging systems, I do like the GE 3D C-arm quite a lot because the footprint in the OR is smaller and it's easy to use for our radiology techs like our traditional C-arms. However we now have to be conscientious as to whether these images marry well with our various guidance/robotics platforms.  

I believe there is going to be a lot of competition between robotics companies and imaging companies and there will eventually be a dominant one or two players in the end. We plan to make more capital purchases along the lines of these enabling technologies in the next year, but we have to be conscientious of these factors.  

Alen Nourian, MD. DISC Sports and Spine Center (Beverly Hills, Calif.): I always think that it is best for a surgeon to own the real estate that they use whether they buy an office building or a surgery center. I plan on buying a medical building in the next 12 months for my own use. Real estate is a good long-term investment for physicians, especially once they retire, to have a source of income after retirement.

Dr. Alex Vaccaro, President at Rothman Orthopaedic Institute (Philadelphia): Peter Swiatek, MD, is matriculating to the Indianapolis Spine Group. When asked what the capital investments he was considering in the next year he responded that there are three primary financial concerns for a graduating young physician-housing/furnishing, investments and transportation.

Housing: As trainees advance from resident or fellow to practicing physician, many are faced with the choice of pursuing homeownership. Buying a house offers long-term stability and the opportunity for building equity over time. Moreover, it’s an investment that can offer tax benefits such as mortgage interest deductions. Lastly, homeownership allows the buyer a chance to personalize the living space to make it their own, which is often limited when renting a property.

Homeownership requires a financial commitment that may not be suitable for everyone. First, the upfront costs of buying a house can be steep especially in today’s interest environment. What was affordable three years ago is no longer affordable today. Physician loans are a tool that can lessen the upfront costs of financing a house by waiving the down payment. However, the buyer must be aware that interest rates are typically higher and the path to building equity can take longer. This can be an issue if the job does not work out and the physician moves jobs or to cities, requiring an earlier than expected sale of the property.

Other issues with home ownership include repairs and upkeep, dealing with higher interest rates (currently around 7.25%), and ultimately fluctuating property values based upon home location. Peter plans to pursue purchasing a home via a physician loan in summer 2024.

Home furnishings: For those who transition from apartment-living to a home, furnishing the home can be a major expense. This expense will likely be highly dependent upon the size and age of the house we purchase.

Investments: With the salary bump that comes with an attending-level job, Dr. Swiatek will be able contribute more significantly to various investments – specifically 401(k) / Roth IRA, ETF and mutual funds, and a 529 savings plan for his children. In general, we recommend that a graduating fellow save 25-30% of their income if possible. Presently the vast majority of fellows participate in their employer’s 401k and plan to further that investment as they transition into a new job. If one's future employer offers a match, we recommend highly that the surgeon contributes enough to take full advantage of this benefit. Second, we support the concept of dollar cost averaging by contributing monthly to various investment vehicles such as ETFs and low fee mutual funds. Lastly, the 529 plan allows one to essentially prepay tuition at today's rates for use in the future. When used for tuition and certain education expenses, the plans are generally tax-free. It is important now to begin this process monthly if you have a young child or infant.

Car: After fellowship, many graduates will need to purchase a new car. Options are lease, buy new, or buy used. Leasing offers lower monthly payments than a car loan, has no long-term commitment, and offers one the opportunity to drive a newer vehicle every few years. Buying allows ownership and equity, without mileage limits, and typically long-term cost savings. Used vehicles offer similar equity opportunities but at a lower cost. Used vehicles, however, often require more maintenance and have lower resale value. We recommend that most graduates initially pursue a used vehicle as the upfront costs are lower compared to a new vehicle, and the long-term costs savings usually are better than leasing.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Albeit capital issuance has been limited following the pressures of pandemia, as near-normalcy has returned, so have requests for capital resurfaced. There are a number of larger purchases like additional O-Arm, bi-planar angiography units and microscopes being ordered, we are carefully assessing augmented reality technology for the spine and its utilization. With the recent addition of three fellowship trained providers, the neurosurgical scope of practice is larger and prospectively prepared for the expanding populace and demands of the region. 

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