The future of spine surgery may depend less on what happens in the operating room than on who controls everything that happens before it.
For decades, spine practices have built their businesses around surgical expertise, procedural volume and, increasingly, ownership of ASCs. But as Medicare moves toward greater accountability for the cost and quality of care, Michael Verdon, DO, a neurosurgeon in Dayton Ohio, believes that model is approaching a turning point.
“The hardest decision in 2027 is whether to own the whole spine episode, including the nonsurgical pathway, or keep owning only the operation,” Dr. Verdon told Becker’s.
It is a consequential distinction for a specialty whose financial incentives have historically centered on surgery. Dr. Verdon owns shares in an ASC and understands the pressure to maintain surgical volume. Yet he argues that spine leaders must increasingly invest in care that may never produce an operation.
The financial stakes are becoming harder to ignore. CMS’ mandatory Transforming Episode Accountability Model, which began in 2026, holds participating hospitals accountable for costs and quality during qualifying surgical episodes, including spinal fusion. In 2027, the Ambulatory Specialty Model will introduce performance-based accountability for selected specialists treating conditions including low back pain.
The programs differ in scope, but both reflect a broader shift toward evaluating care beyond individual procedures. For Dr. Verdon, the question is whether spine practices will adapt before those financial pressures force their hand.
The blind spot in surgical training
Dr. Verdon’s perspective is shaped by an unusual career path. Before becoming a neurosurgeon, he worked as a physical therapist, treating patients with back pain and radiculopathy. He saw firsthand how appropriate nonsurgical treatment could improve symptoms and sometimes eliminate the need for an operation.
But when he entered surgical training, the emphasis changed. Rather than learning how different therapies could help patients recover, he focused primarily on identifying conditions that required surgical intervention.
“I think a problem is each group doesn’t know what the other is capable of doing or producing,” he said.
That disconnect has consequences when surgeons are expected to coordinate care beyond their own specialty. A patient may arrive having completed physical therapy, but the surgeon may have limited insight into which techniques were used or whether the treatment addressed the underlying condition. Meanwhile, nonsurgical clinicians may lack a clear understanding of when an operative evaluation is appropriate.
Dr. Verdon believes those gaps will become increasingly difficult to overlook as reimbursement models place greater emphasis on coordinated treatment. Under the Ambulatory Specialty Model, selected specialists will be evaluated on measures including quality, cost and care coordination, with performance beginning in 2027 affecting Medicare payments in 2029.
For participating physicians, the implications extend beyond achieving strong surgical outcomes. They will also need to understand how patients move through treatment and whether that care is appropriate and cost-effective. Dr. Verdon worries that many surgeons have not been adequately prepared for that responsibility.
The patient shouldn’t have to find the pathway
If Dr. Verdon could redesign one part of spine care, he would start before the first specialist appointment. Patients with back pain can move through multiple consultations, imaging studies, injections and therapy appointments before reaching the clinician best suited to their condition.
The problem, he argues, is not necessarily poor treatment. It is care delivered inefficiently or at the wrong point in the patient’s journey. “It’s not bad care. It’s wasteful care,” he said.
His ideal solution is an intelligent intake system that evaluates symptoms and directs patients to the appropriate clinician from the beginning. Someone who needs physical therapy should not have to visit a surgeon first. A patient who needs surgical evaluation should not have to move through unrelated appointments simply to reach one.
Such an approach would challenge longstanding referral patterns in which surgeons often serve as the default entry point for spine complaints, regardless of whether surgery is likely.
It could also reshape the economics of outpatient spine care. Dr. Verdon believes more effective triage can improve the flow of appropriate surgical candidates into a practice while directing other patients toward treatments better suited to their needs.
For ASCs, that distinction matters. A practice that consistently identifies patients who are ready for surgery, medically appropriate for outpatient treatment and likely to benefit from a focused procedure may be better positioned to maintain predictable surgical volume.
“The biggest opportunity for revenue gain begins with getting the right patients into the office,” he said. In other words, the financial performance of an ASC may depend as much on the effectiveness of the practice feeding it as on what happens inside the facility.
How one practice cut surgical delays by more than 100 days
For Dr. Verdon, the value of managing the care pathway is not merely theoretical. He described working with a developing practice where patients routinely encountered delays between their initial consultation and surgery.
The problems varied. Some patients were waiting for medical clearance. Others lacked the documentation needed for prior authorization, including records of previous therapy or injections. Without a systematic way to identify those bottlenecks, the practice struggled to determine where intervention would make the greatest difference.
Dr. Verdon and his team began collecting data at individual points in the process, tracking where patients were getting stuck and identifying recurring patterns. The findings allowed practice leaders to make targeted changes, including improving authorization support and coordinating more closely with clinicians responsible for surgical clearance.
Within a year, Dr. Verdon said, surgical wait times fell from approximately 130 days to fewer than 30. The experience reinforced a lesson he believes many spine practices have yet to fully embrace: Improving care requires understanding what happens between appointments, not simply what happens during them.
Too often, he said, organizations rely on retrospective reports that reveal problems months after they occur. “You’re looking back three to six months, like looking in the rearview mirror while driving forward,” he said.
Real-time data, by contrast, can help leaders identify delays as they develop and determine whether they stem from payer requirements, missing documentation or limited access to other specialists.
But Dr. Verdon cautions against assuming the same solution will work everywhere. Two practices just 20 miles apart may serve populations with vastly different insurance coverage, medical needs and access to care. Effective pathways must account for those differences rather than impose identical processes on every market.
The business discipline spine surgery has overlooked
Dr. Verdon learned the value of standardization shortly after opening his private practice, when the COVID-19 pandemic disrupted operations. He and his wife sat down at their dining room table and documented every step of the patient journey, from registration through discharge.
Staff initially resisted the detailed procedures, but missing records, incomplete treatment histories and prior authorization delays reinforced the need for a consistent process. The experience reshaped his approach to practice management. Without a repeatable, measurable process, he argues, practices cannot reliably identify or correct inefficiencies.
He sees similar challenges across spine care, where physician training and local preferences contribute to wide variations in treatment and referral patterns. Standardization does not mean treating every patient identically, but establishing processes that can be measured and improved.
Dr. Verdon also worries younger surgeons lack exposure to the business operations he learned during his private practice-based training.
“What feeds the hospital is the practice,” he said. As organizations invest in surgical facilities and technology, he believes they risk overlooking the systems responsible for getting the right patients into those operating rooms.
The choice ahead
Taking responsibility for the entire spine episode requires investing in nonsurgical care, coordinating treatment and measuring success beyond surgical volume, even when that means fewer operations.
Dr. Verdon believes practices that can demonstrate the value of their full care pathway will be better positioned as payers demand greater accountability. Those focused solely on surgery risk ceding more control to outside organizations.
“Until you document every step from patient registration through discharge, you have a theory of how you treat patients, not an objective, documented process,” he said.
For spine leaders, the next competitive advantage may not be another operating room or a larger ASC. It may be knowing which patients should reach the operating room in the first place.
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.
