When Christopher Tomaras, MD, a neurosurgeon and owner of Alpharetta, Ga.-based Axion Spine & Neurosurgery, began practicing in Atlanta in 1998, hospital employment was barely part of the physician landscape. Nearly three decades later, he looks around the city and sees something close to the opposite.
“There’s one other neurosurgery practice in the city that is private,” Dr. Tomaras told Becker’s.
His practice has survived the consolidation around it. But independence no longer means simply owning a practice and generating enough surgical volume to support it.
The model Dr. Tomaras describes is more deliberate: an ambulatory surgery center, a larger nonsurgical spine operation around its surgeons, a payer mix tilted toward commercial insurance and cash, and increasingly, technology aimed at keeping labor costs from rising alongside the practice.
It is a model built around a reality Dr. Tomaras confronted nearly 20 years ago: Professional fees alone were not producing the economics he needed. So he made a decision that would reshape his practice.
The month that changed his practice
Dr. Tomaras can still remember the month he opted out of Medicare. It was August. He performed roughly 14 or 15 lumbar fusions, he recalled, and about 12 involved Medicare patients. Then the collections arrived.
“They were just in the cellar,” he said. “I said, ‘I just can’t. My career is going to be short if I keep doing this.’”
He opted out of Medicare and, in retrospect, calls it “the best decision I ever made.”
The trade-off was significant. Dr. Tomaras said leaving Medicare substantially affects the patient population he can treat. He still sees some Medicare patients who pay cash, but he said that population has shrunk as hospital employment has expanded across Atlanta.
Years ago, he said, Medicare patients who struggled to find access sometimes chose to pay privately. Today, employed physicians whose compensation is based on relative value unit productivity have less personal financial incentive to distinguish among patients based on insurance status.
Axion has instead concentrated largely on commercially insured patients, along with some workers’ compensation, personal injury and cash-pay care. Dr. Tomaras said that model has allowed the practice to operate more efficiently and spend more time with the patients it treats.
When a Medicare patient pays cash for surgery, for example, he said he gives the patient his cellphone number. If the patient goes home the same day, he calls that night. If the patient remains hospitalized, he personally rounds rather than sending a physician assistant.
“We try to provide that higher level of care,” he said.
But opting out solved only one piece of the independence equation.
The referral pipeline is becoming the battleground
The pressure Dr. Tomaras worries about most now begins before a patient ever reaches his office. As health systems bring primary care physicians and specialists under the same umbrella, independent practices can find themselves outside increasingly integrated referral networks.
“If we lose the ability to capture patients because of all this vertical integration between primary care and specialists, that’s what worries me,” he said.
Axion has responded in an unconventional way. Atlanta has a substantial chiropractic community, and Dr. Tomaras said it is rare for him to see a patient who has not already been treated by a chiropractor. Rather than relying only on traditional physician referrals, his practice has spent years cultivating relationships with chiropractors.
The physicians make themselves readily available, including sharing cellphone numbers so chiropractors can reach them for help reviewing an MRI. The strategy gives Axion another way to reach patients earlier in the referral chain.
“We’ve made a real effort to build relationships with chiropractors and make them feel accepted and welcome,” Dr. Tomaras said. For an independent practice surrounded by larger systems, preserving those outside referral relationships has become part of preserving independence itself.
Why the ASC became essential
Ask Dr. Tomaras what an independent spine practice will need to survive another decade, and his answer comes quickly.
“You have to have a surgery center,” he said.
He arrived at that conclusion after operating under a much broader ancillary model. His former practice had an ASC, MRI, physical therapy and aquatic therapy. When he and his partners formed their current practice, they looked at the numbers again.
The surgery center stood out. So they built the new practice around an ASC but did not replicate every ancillary service. They decided against adding MRI and physical therapy, for example. Physical therapists can be a source of referrals, and Dr. Tomaras said the practice did not want to alienate them by competing for the same business. The ASC was different. It gave the practice access to ancillary revenue beyond the professional component of surgical care.
For Dr. Tomaras, that has become fundamental to the economics of remaining independent. But the ASC alone is not enough.
Why the next hire may not be a surgeon
The second piece of Axion’s model challenges the idea that growth in a spine practice necessarily means adding more surgeons. Dr. Tomaras wants more physiatrists.
“Ideally, for every surgeon, you probably need three physiatrists or pain specialists,” he said.
His reasoning starts with the patients coming through the door. Dr. Tomaras estimates only 15% to 20% ultimately need surgery, while many more can receive injections or other nonsurgical care. That makes the nonsurgical side of the practice an important part of the model rather than simply a pathway to surgery.
“We didn’t realize how successful that model could be until about 2015,” he said. Dr. Tomaras said the practice expects to add more physiatrists before considering another surgeon.
It represents a subtle change in how an independent spine practice can be structured. Surgery remains important. But the business does not have to depend entirely on putting more surgeons in operating rooms.
Can AI keep overhead from climbing?
The next experiment is happening farther away from the operating room. Axion has begun using an ambient AI scribe through one of Dr. Tomaras’ partners and has explored technology designed to move patient information from one office visit to the next more efficiently.
Dr. Tomaras is not expecting AI to transform the practice overnight. His goal is more practical: keep overhead from climbing as the practice grows. He pointed to what he has heard from physicians already adopting the technology. Rather than eliminating existing positions, some practices are using AI to avoid adding employees at the same pace as they expand.
“It’s not like the ones that adapted have replaced employees,” he said. “They’re just not adding new employees as they grow.”
If Axion can do the same, Dr. Tomaras believes technology could help stabilize overhead even as volume increases. For now, the practice is moving cautiously. It is testing some tools, exploring others and watching what peers adopt before committing more broadly.
That caution reflects the larger strategy Dr. Tomaras has followed for years. There has been no single decision that preserved independence. The practice has repeatedly adjusted around the pressures threatening it.
What independence costs now
Even for Axion, the future is not assured. Dr. Tomaras worries about surgical volume, whether economic strain is causing patients to defer care and, most of all, whether consolidation will give hospitals and large groups greater control over how patients reach specialists.
His concern is especially acute for the younger physicians in his practice. “Being one of the last two private practices worries me, especially for my younger partners,” he said.
Still, he hopes the pendulum eventually swings back toward private practice. If it does, the practices that remain may look very different from those he knew when he entered medicine, built around ASCs and nonsurgical care, referral networks outside integrated health systems and technology that allows them to grow without continually adding staff.
Some may also have to make difficult decisions about which payers they can afford to accept.
Nearly three decades after Dr. Tomaras entered an Atlanta market dominated by independent physicians, the question is no longer whether a small spine practice can simply remain independent. It is how much the practice has to change in order to stay that way.
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.
