A spine surgeon who performs more procedures generates more relative value units. But what about one who prevents an unnecessary operation, reduces complications or gets patients to the right treatment faster?
Those contributions can create significant value without necessarily generating more RVUs, healthcare leaders told Becker’s.
As reimbursement tightens, spine surgeons are increasingly expected to demonstrate outcomes, efficiency and cost control, even as compensation remains largely tied to billable services. Here are six shifts that could reshape how their work is valued.
1. Avoiding an operation could become as valuable as performing one: Traditional RVU models reward billable services but do not necessarily recognize the benefits of avoiding unnecessary interventions.
Jed Vanichkachorn, MD, medical director of orthopedics and spine at Cincinnati.-based Bon Secours Mercy Health, is taking a different approach through the system’s Richmond, Va.-based Spine Institute, which launched in June.
The program uses nurse navigators and AI-assisted triage to direct patients toward appropriate surgical or nonsurgical care. Rather than focusing solely on surgical volume, the institute tracks time to evaluation and the percentage of patients who ultimately undergo surgery. Both measures have been declining as the pathways take hold.
“If you show up at the wrong place at the wrong time, at a surgeon’s office at the wrong time, you may get a surgery that you don’t need,” Dr. Vanichkachorn told Becker’s.
The model reflects a growing interest in rewarding appropriate treatment rather than simply more procedures. It also raises a compensation question: If better triage reduces unnecessary operations and improves access, how should surgeons be rewarded for those gains?
2. The procedures surgeons choose can work against their financial interests: Procedure-based reimbursement does not always align with an operation’s clinical value, technical demands or cost. Peter Derman, MD, an endoscopic and minimally invasive spine surgeon in Dallas, has raised concerns that traditional reimbursement can financially favor larger fusion procedures over smaller, less invasive operations, even when the latter may be more appropriate.
As practice costs increased and reimbursement for smaller procedures declined, Dr. Derman transitioned to a direct-pay model. Complex revisions and deformity corrections present a different challenge, requiring extensive operating time, expensive implants and postoperative resources that may not be adequately reflected in reimbursement.
Surgeons told Becker’s in August that they identified endoscopic decompressions, complex fusions and revision surgery among the procedures facing significant reimbursement pressure. The challenge for alternative compensation models is recognizing those differences without encouraging certain procedures or discouraging surgeons from treating complex patients.
3. Outcomes data could become a financial asset: For spine groups seeking stronger payer contracts, demonstrating outcomes may become as important as procedural volume. Measures such as functional improvement, complications, readmissions and total episode spending can help practices demonstrate the value of their care. But determining which outcomes can fairly be attributed to an individual surgeon remains difficult.
Vijay Yanamadala, MD, a spine surgeon at Hartford (Conn.) HealthCare, identified differences in patient complexity as a major obstacle to standardized bundled-payment models. Patients undergoing similar procedures can have dramatically different medical histories and recovery needs. Without adequate risk adjustment, outcomes-based compensation could penalize surgeons who treat more complex cases.
Practices that can reliably measure outcomes while accounting for those differences may gain an advantage in future payer negotiations, he said.
4. Bundled payments could reward efficiency beyond the procedure: Bundled-payment arrangements shift financial accountability from individual services to an entire episode of care, creating incentives to coordinate treatment and manage costs.
Some orthopedic surgeons are already seeing financial benefits.
“I make more now on a joint in a bundle program than I ever did on fee for service,” Brian Curtin, MD, an orthopedic surgeon at Charlotte, N.C.-based OrthoCarolina Hip and Knee Center, told Becker’s. The opportunity depends on understanding costs, managing sites of care and building infrastructure to coordinate surgical episodes.
Spine surgery presents additional challenges because of greater variation in patient complexity, procedure selection and recovery needs. Still, bundled payments offer a potential way for surgeons and their organizations to share in the financial benefits of efficient care.
5. The most valuable work may happen outside the operating room: Some spine surgeons are reconsidering where their organizations generate financial value.
Michael Verdon, DO, a spine surgeon at Dayton (Ohio) Neurologic Associates, has argued that traditional productivity measures overlook the importance of patient intake, clinic operations and referral management.
His practice developed a digital intake system to screen referrals and identify operational bottlenecks, including prior authorization delays. Dr. Verdon said his surgical output remained steady even after a competing health system reduced his referral volume by 50%, because the practice was using its remaining referrals more effectively.
The approach challenges the assumption that increasing operating room volume is the only way to strengthen practice economics. It also raises questions about how to reward surgeons who improve access and operational performance without generating proportionally more RVUs.
6. The next model may reward ownership, not just production: As professional reimbursement declines, some spine surgeons are looking to ASC ownership and ancillary services to generate revenue beyond traditional RVU-based compensation.
John Peloza, MD, founder and owner of Chesterfield, Mo.-based Peloza Spine, said declining physician payments are making alternative revenue streams increasingly important.
“It’s just death by a thousand cuts,” Dr. Peloza told Becker’s. “So you’ve got to have other sources of revenue streams. So the biggest one is ancillaries at facilities.”
He said ASC ownership allows surgeons to participate in facility revenue as more spine procedures move outpatient. These arrangements do not replace RVUs as a measure of individual productivity. Instead, they give surgeons opportunities to participate in the broader economics of care rather than relying solely on professional fees.
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.
