Insurance hurdles, consolidation and minimally invasive surgical advancements are among trends that spine and orthopedic leaders are especially worried about.
The 22 leaders featured in this article are speaking at Becker’s 22nd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, set for June 18-21 at the Swissotel Chicago.
If you would like to join the event as a speaker, please contact Carly Behm at cbehm@beckershealthcare.com.
As part of an ongoing series, Becker’s is connecting with healthcare leaders who will speak at the event to get their insight on thought-provoking questions within the industry. The following are answers from event speakers, lightly edited for clarity.
Question: What is the most dangerous trend in spine and orthopedics right now?
Caleb Ashmore, DPT. Orthopedic rehabilitation services supervisor at Harris Health System (Bellaire, Texas): A huge problem is the access that everyone has to the internet in their pocket right now. There is so much misinformation out there due to the many untrained individuals putting out recommendations on social media and making videos like ‘The 5 Best Exercises for Your Lower Back.’ Many people don’t give conservative management a proper chance before they opt for a surgical intervention, and this can lead to unnecessary potential complications, risk of infections, chronic pain, and prolonged disability. Patients should seek out a physical therapist who is a board-certified orthopedic specialist and make sure that they get a program tailored to their specific needs rather than a cookie cutter program given out by someone without the proper credentials to be suggesting it in the first place. A good rule of thumb is that if you haven’t been assessed and given a specialized home exercise program, you haven’t “failed conservative management” or really “tried PT” yet.
Omkar Baxi, MD. Kaiser Permanente (Woodbridge, Va.): I think the most dangerous trend in orthopedics and medicine in general today is the spread of misinformation. Today’s tech has so many amazing applications and advancements but can also cause significant damage. Social media content can quickly become viral, and typically the more sensational topics will gain more visibility despite having fewer real world applications. With the rise of generative AI that will rely on these data points, it will be even easier to get medical information that may not be accurate or applicable. While physicians have always had a responsibility to teach and educate, I anticipate that more of our time may be needed to fine tune or contextualize the (often incorrect) information that patients may get through the internet. We should also take on the responsibility to disseminate accurate medical knowledge to patients and the public alike and help train the AI models to recognize and distinguish between reliable and unreliable information sources.
Basil Besh, MD. Surgeon at FORM Hand, Wrist & Elbow Institute (Fremont, Calif.): I see two trends that are worrisome. The first is consolidation, which creates imbalances in market leverage. The second is private equity. What started out as a lifeline for many practices has often not panned out as entities are streamlined and repackaged for sale in the private equity market. Initially we were seeing physician groups, then health systems and now even insurance companies have been acquired by private equity.
Brian Bizub. CEO of Raleigh (N.C.) Orthopaedic Clinic: One of the most concerning trends in spine and orthopedic care today is the increasing growth burden of insurance-related requirements, such as preauthorizations and peer-to-peer reviews. These administrative hurdles often result in significant delays in delivering medically necessary care, which can lead to poor patient outcomes, increased risk of complications, dissatisfaction and higher overall costs due to the added administrative burden.
Additionally, with declining reimbursements and a shift toward performing more complex orthopedic and spine procedures in ambulatory surgery centers, there is rising concern. Moving high-acuity cases into ASCs without ensuring that staff and anesthesia providers are adequately trained to manage patients with multiple comorbidities could pose serious safety risks. Maintaining high-quality care and prioritizing patient safety must remain central as this transition continues.
Another challenge is the rising cost of surgical implants, which, when paired with declining reimbursements, places financial strain on facilities. Advanced technologies such as neuromonitoring and robotics, while essential for improving efficiency and maintaining safety, are costly and currently lack meaningful financial incentives for ASC adoption apart from enhancing surgeon workflow.
If insurance carriers are to play a meaningful role in lowering healthcare costs, they must support the safe transition of appropriate procedures from hospitals to ASCs. This includes being fiscally responsible in covering advanced technologies and aligning policies to support timely and high-quality patient care.
Adam Bruggeman, MD. Orthopedic Surgeon at Texas Spine Care Center (San Antonio): The consolidation of physician practice into vertically integrated networks has tremendous impacts on quality, cost and access to care. Without payment reform and relief from regulatory burdens, this trend will continue until there are no private practicing physicians.
Paul Bruning, DHA. Neuromusculoskeletal Service Line Director of Sutter Health’s Silicon Valley Division (Sacramento, Calif.): As these critical funds dwindle, top physician-scientists may be compelled to leave the U.S. in search of better-funded research opportunities abroad. This brain drain threatens to erode the nation’s longstanding position as a global leader in medical innovation. The loss of both financial resources and leading minds in the field will have lasting, potentially irreversible consequences for patient care, clinical advancements and the future of orthopaedic medicine in the U.S.
Janet Carlson, MSN, RN. Vice president of ASC operations at Commonwealth Pain & Spine (Louisville, Ky.): There are many trends in spine and orthopedics that are dangerous to patients and providers. The first being declining reimbursement, surgeons cannot continue to work any harder to earn the wage today that they did last year by seeing more patient volume. The constant cuts to physician reimbursement are not sustainable and will drive many surgeons to leave the conventional payer structure and instead opt for a concierge all-cash pay model. This steady decline and increased financial pressure affect hospitals, ambulatory surgical centers, and surgeons, making it harder to deliver high-quality care-especially for an aging population with complex medical needs. The next major issue is the increase in prior authorizations and administrative burden that causes surgical delays. The unnecessary complexity of insurance processes, especially prior authorizations, is creating a literal “minefield” for providers. These administrative hurdles delay care, increase burnout, and can negatively impact patient outcomes. I don’t know a single surgeon, nurse, anesthesiologist, CRNA, nurse practitioner, physician assistant, or administrator that is not having this ongoing dialogue around the many unnecessary barriers to providing safe, affordable and accessible quality ambulatory surgical care to our patients.
Anthony DiGiorgio, DO. UCSF Health: The most dangerous trend is the destruction of independent practice and loss in physician autonomy. When practices are acquired by ever enlarging hospital corporations, quality patient care becomes secondary to metric gaming and number crunching. Physician-led care is replaced by administrator-led care and costs skyrocket as the large monopolies exploit their leverage. If the trend continues, there will be no independent practice left, only corporations who treat patients and physicians like revenue maximizing widgets.
Bruce Feldman. Associate Administrator at SUNY Downstate Medical Center (New York City): I feel that the most dangerous trend in spine and orthopedics right now is reimbursement not keeping par with the cost of doing these cases in the ASC. Many third-party payers continue to deny coverage for implants and related supplies that are required to perform these cases especially with joint replacement which are costly to perform. Reimbursement for these cases very often barely covers the cost and overhead for performing these higher acuity level cases as we continue to see an outward migration of Orthopedic & Spine cases from the hospital to the ASC setting. We need to make sure going forward that ASCs receive the appropriate compensation/reimbursement for doing these cases in a lower and more cost effective as well as higher quality outcomes that patients receive in the ASC environment.
Anthony Giuffrida, MD. Cantor Spine Center at the Paley Orthopedic & Spine Institute (Fort Lauderdale, Fla.): One of the most dangerous trends in spine and orthopedics today is the escalating interference of insurance companies in clinical decision-making. There have been increasing denials for medically necessary procedures and imaging, even after patients have exhausted conservative treatments. This not only delays care but also undermines physician autonomy and erodes the physician-patient relationship. The cumulative effect is a healthcare environment where administrative burdens compromise timely, effective treatment, leading to poorer outcomes and heightened physician burnout.
Brandon Hirsch, MD. DISC Sports and Spine Center (Newport Beach, Calif.): The most dangerous trend in spine and orthopedics right now is certainly the longstanding, ongoing devaluation of physicians’ work. For decades CMS has decreased what they compensate physicians for the work that they do, known as a “professional fee.” Professional fees have historically not been adjusted for changes in the cost of generating that revenue, i.e. inflation. At the same time, facilities have received annual increases in compensation, known as a “facility fee,” to account for inflation. Almost all commercial insurance companies utilize the Medicare fee schedule to determine how they reimburse physicians, meaning that physicians treating patients outside of Medicare have also had their work devalued for many decades. The end result is that physicians’ professional work provides such little revenue relative to the cost of providing it that it is difficult to impossible to sustain a medical practice dependent upon insurance reimbursement. As a consequence, independent physicians are either changing careers, retiring, opting out of the Medicare system or becoming employed by facilities at subsidized rates. This shift has consolidated power in the hands of large health systems with the expected effects on the quality of care and the patient experience. The shift has also encouraged replacement of physicians in nearly all areas of medicine with midlevel providers with less training as they are less expensive to employ. This has created the nightmare of a healthcare system that we have currently, where treatment decisions, care quality, and patients’ experience are all dictated by the insurer/health system, rather than those who spent a decade or more of their life training to care for other human beings. Despite being a physician, I am frankly frightened for what my healthcare will look like in the future when I really need it.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: I think this topic has multi facets. From the business standpoint, the independent physician is dwindling. I believe healthcare system employment or even private equity will only raise prices, limit access, and make healthcare a commodity. It doesn’t give better clinical results.
From an orthopedic standpoint, direct marketing to patients of new technology by implant companies is torture. Patients come in, asking for certain approaches or certain technologies, even though they may not be candidates for those. For young guys, it’s really tough to close the deal if the patient is not a candidate for that particular surgery they’re looking for.
Zwade Marshall, MD. Founder/Chief medical officer of Regenerative Spine & Pain Specialists (Fayetteville, Ga.): One of the most dangerous trends in spine and orthopedics today is the overutilization of procedures driven more by reimbursement incentives than by patient-centered outcomes. As private equity and corporate ownership expand in musculoskeletal care, there is increasing pressure on providers to prioritize volume over value. This can lead to premature surgical interventions, fragmented care, and erosion of the physician-patient relationship. Additionally, the proliferation of minimally trained practitioners performing high-risk interventions without appropriate oversight poses a safety risk. We must recommit to evidence-based, multidisciplinary care models that prioritize long-term function, quality of life, and ethical stewardship of patient trust.
M. Craig McMains, MD. Spine surgeon at OrthoIndy (Indianapolis): One of the most dangerous trends in spine and orthopedics right now is how fast physician reimbursements are dropping. Medicare payments are going down again in 2025 by 2.93%, and when you adjust for inflation, spine surgery reimbursements have actually fallen nearly 34% since 2001. This is a targeted attack on physicians, as facility fees have increased during this time span. At the same time, surgeries are getting more complex and the paperwork and prior authorization hurdles just keep piling up, delaying care and burning doctors out. We are also staring down a wave of aging patients who will need more orthopedic care while a huge portion of our workforce is nearing retirement. If this does not change, we are going to lose a lot of smart young talent to other fields. Patients, especially in our underserved areas, will be the ones who suffer most.
Sean Nguyen. System director of interventional pain service line at Ochsner Health (New Orleans): One of the most concerning trends in spine and orthopedic services today is the over-utilization and fragmentation of care across the healthcare delivery system. Patients are often caught in a cycle of trying to manage acute symptoms while seeking long-term, comprehensive solutions. This can lead to duplicated services, inconsistent diagnoses, unnecessary interventions, and significant delays in receiving the right care.
We frequently see patients struggle to navigate the complex landscape of large health systems and siloed private practices, unsure whether their pain is primarily musculoskeletal, neurological, psychological, or a multifactorial combination. This confusion not only leads to inefficiencies but also puts patients at risk for prolonged suffering, increased costs, and suboptimal outcomes.
At Ochsner Health, we recognized this challenge and responded by relaunching our Spine Care program to center around coordinated, patient-centered care. Our approach fosters collaboration among interventional pain specialists, physical therapists, physiatrists, neurosurgeons, and orthopedic spine surgeons to streamline access and treatment pathways. By integrating services and breaking down silos, we’re able to address both the immediate pain and the underlying causes with greater precision and efficiency.
In addition, we’re leveraging telemedicine to extend our reach into rural communities, ensuring patients have timely access to multidisciplinary expertise regardless of location. This coordinated model not only improves outcomes but restores trust in the system by guiding patients through a seamless and comprehensive care journey.
Thomas Loftus, MD. Austin Neurosurgical Institute: Without question, the most dangerous trend in spine right now is the performing of “spine surgery” by wholly unqualified physicians. There is a nationwide epidemic of doctors without any formal surgical training performing spinal implant surgeries on unsuspecting patients. The significant lack of technical abilities aside, the surgeries are often counter to basic biomechanical spine principles, not clearly indicated, and seemingly unmonitored in whether they achieve a successful radiographic or clinical outcome. It is really casting a dark shadow over what is supposed to be the safe, regulated, and principled practice of medicine.
Denis Patterson, DO. Nevada Advanced Pain Specialists (Reno): One of the most dangerous trends in spine currently is the recent advancements of minimally invasive spine surgery. These advancements have led to issues with deciding where they fit into patient treatment algorithms and who should be performing the procedures (interventional pain vs. neurosurgery or orthopedic spine surgery vs. both). Standardized protocols on both issues need to be established.
Mick Perez-Cruet, MD. Professor and Vice Chairman of the Department of Neurosurgery at Oakland University William Beaumont School of Medicine and President and founder of Michigan Minimally Invasive Neurosurgical Institute (Waterford): The most dangerous trend is decline in reimbursements for patient care services provided by specialists. Physicians, particularly in private practice, are finding it increasingly more difficult to cover practice expenses. This trend leads to physician frustration, burn out, and potentially unnecessary surgeries. As CMS continues to devalue reimbursement for care, more physicians will opt out of medicare and pursue fee for service options. This will leave more and more patients unable to access quality specialty care, like spine disorder treatment.
Melissa Rice. Administrator at Loyola Ambulatory Surgery Center (Oak Brook Terrace, Ill.): The most dangerous trend in spine and orthopedics currently is the increasing prevalence of outpatient procedures without adequate patient selection and follow-up protocols. As surgical techniques advance and minimally invasive procedures become more common, there is a growing tendency to perform complex spine surgeries and joint replacements in outpatient settings. While this trend offers benefits like reduced costs and shorter recovery times, it also poses significant risks. These include higher rates of complications such as infections, thromboembolic events, and surgical site issues when patients are not appropriately monitored post-operatively. Additionally, inadequate preparation and patient education for outpatient procedures can lead to unrealistic recovery expectations and dissatisfaction. Therefore, ensuring rigorous patient selection criteria, thorough preoperative assessments, and comprehensive follow-up care are critical to mitigate these risks and optimize outcomes in outpatient spine and orthopedic surgeries.
Jacob Rodman. CEO of Raleigh (N.C.) Neurosurgical Clinic: I would say the most dangerous trend in spine and orthopedics right now is the inability of patients to receive timely and appropriate access to care. The number of prior authorizations and delays in care from insurance companies has increased drastically over the last few years and we are seeing patients have to make extremely difficult decisions to proceed with life altering surgery and deal with the insurance company denial (and potentially hundreds of thousand dollars in hospital costs) or delay care while insurance companies take weeks or months to approve necessary, safe surgery or treatment. This trend cannot continue as it is extremely dangerous to patient and patient care.
Katherine Wagner, MD. Neurosurgeon at Ventura (Calif.) Neurosurgery: I think the most dangerous trends are payer problems. Between prior authorizations and clawbacks, physician offices don’t know if 1) they can treat patients and 2) if they’ll get paid for treating patients.
Imagine if you went to the mechanic after paying $2,000 to get your transmission fixed and demanded $1,000 back because you felt that you overpaid; you’d be laughed out the door. However, this is the reality for physician offices. We are left fighting to get services approved, covered, and then to hold onto the money that we get in reimbursements. This is a really dangerous trend that increases costs for the patients and our offices, ultimately increasing the cost of healthcare for everyone.
Connie Wilson, RN, MSN. Director of patient care services/nurse executive at Shriners Children’s Lexington (Ky.): One of the most concerning trends in spine and orthopedics right now is the overutilization of spinal surgery — particularly complex procedures like spinal fusion — in cases where conservative treatment may be equally effective or more appropriate.
