Spine practices are facing mounting financial pressure as reimbursement declines, operating costs rise and administrative burdens grow. From prior authorization and payment delays to staffing costs and shifting care models, spine leaders are rethinking how to remain financially sustainable without compromising patient care.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What financial pressure is having the biggest impact on your practice today, and how are you responding?
Here is what several spine leaders shared with Becker’s:
Todd Albert, MD. Surgeon-in-Chief Emeritus at Hospital for Special Surgery (New York City): The biggest financial pressure on our practice today is the widening gap between the cost of delivering high-quality care and reimbursement. Labor, technology, supplies and administrative costs continue to rise, while physician reimbursement remains flat or declines in real terms. We are responding by becoming more disciplined about operational efficiency, expanding value-based and ambulatory care models, and using technology, including AI, to reduce administrative burden and improve productivity.
Many are bridging the gap through strategic development and expansion of ancillary services, including ASCs, orthotics and prosthetics, and physical therapy.
Ultimately, the challenge is to take cost out of the system without compromising the quality, access or patient experience that define great care.
James Caruso, MD. Pediatric Spine Surgery Fellow at Cedars-Sinai Medical Center (Los Angeles): Prior authorization requests for pediatric spine surgery are becoming more frequent and onerous. Reviewers often lack pediatric spine expertise, and insurance denials can happen one to two days before a scheduled surgery, which delays care for children and incurs administrative costs.
In response, we have added AI-assisted literature reviews to our clinical documentation, which provide thorough and timely evidence-based support for our surgical plans.
Peter Derman, MD. Endoscopic and Minimally Invasive Spine Surgeon and Founder of Peter B. Derman, MD. (Dallas): The U.S. healthcare system financially incentivizes big fusion surgeries over outpatient, ultra-minimally invasive decompressions. As practice costs rise while payments for smaller procedures decline, there comes a point where maintaining a focus on endoscopic techniques becomes unsustainable in the traditional system.
Faced with that reality, I realized I had three options: perform more large surgeries rather than endoscopic procedures, despite the clear patient-centered advantages of less invasive care; treat patients like cattle and see an extremely high volume just to make the math work; or break free of a broken system and build a practice dedicated to providing minimally invasive solutions while giving patients the attention they deserve.
I was unwilling to compromise the quality of care I provide, so I chose the third path. I recently transitioned my practice to an independent, direct pay model to protect the doctor-patient relationship, maintain clinical integrity and ensure I can always focus on what is best for the person in front of me. While I do not accept insurance for consultations or my surgical fees, patients can still use their existing insurance to cover related costs, such as facility fees, anesthesia and imaging. My success is no longer measured by how long my waitlist is; it is measured by how quickly and seamlessly patients get answers and relief.
Thomas Dowling, MD. Founding Partner and Orthopedic Spine Surgeon at Long Island Spine Specialists (Commack, N.Y.): The primary issue surrounds the expenditure of time and money pursuing the ever moving target of prior authorizations. This is both for the surgeon and the office staff. Even then, there is still the possibility that payment may not even be forthcoming when billing is then submitted.
Quentin Durward, MD. Neurosurgeon at The Center for Neurosciences, Orthopaedics & Spine (Dakota Dunes, S.D.): At the age of 72, and whilst I am slowing down and working half-time, private practice neurosurgery became financially untenable 2 years ago. Although my production numbers remained healthy, bringing in over $800,000 per year in receipts, the fixed and variable practice overhead assigned to me proportionally ate aggressively into my receipts to a point that it was hardly worth working. But I still love practice and operating, andI needed a satisfying answer.
The solution was to become an employee of my group practice. The financial burden and stress has been largely ameliorated, yet I earn an income I feel is fair. Interestingly, my production numbers have remained above half of my previous production when I was actually in full time practice.
Brandon Hirsch, MD. Orthopedic Spine Surgeon at DISC Sports and Spine Center (Newport Beach, Calif.): Without question, the biggest financial pressure on my practice is declining reimbursement. Staff wages, rent, malpractice premiums and supply costs rise with inflation while physician payments decline, creating an increasingly unsustainable environment for independent practices. Most patients would be shocked by what Medicare pays for care. Reimbursement for office visits is far lower than many assume, and surgical payments often include months of follow-up care. A single-level lumbar microdiscectomy, for example, has a 90-day global period covering related visits, calls and procedures. From that payment, the practice must cover overhead before the physician is paid anything.
Independent physicians also have little negotiating power with major insurers, whose contracts are generally tied to the Medicare fee schedule, sometimes 10% to 15% above Medicare and sometimes below it. That schedule has been cut nearly every year for 25 years without accounting for rising practice costs. Meanwhile, hospital-owned facilities receive annual payment increases and can be paid several times what the surgeon receives for the same operation. Facility fee revenue also allows health systems to subsidize staff salaries, an advantage independent practices lack.
As a result, physicians are leaving independent practice for health systems, exiting insurance or leaving medicine altogether. Patients ultimately pay the price through longer waits for physicians and surgery and conditions that can go undiagnosed for years.
Philip Louie, MD. Spine Surgeon and Medical Director of Research and Academics at Virginia Mason Franciscan Health (Seattle): Non-clinical personnel. Research coordinators, education staff, outreach coordinators and data people all get evaluated against a revenue line they don’t generate directly, so when margins tighten those are the first positions to go. But that work doesn’t go away and remains incredibly important to any clinical program. I’ve tried to stop arguing for these roles on principle and start measuring what they produce and quantifying the value they provide to the health system. Not an easy task by the way, but one that we all need to learn to do better.
The other pressure is capital spending on enabling technology. Many larger enabling technologies carry large price tags, and most systems lack a consistent way to decide which ones are worth buying. Part of the problem is that the people making the decision and the people living with it are rarely the same. A hospital administrator, a surgeon, a payer and a patient are all looking at the same purchase and weighing completely different things, and we tend to run the conversation as if there’s one answer. We’ve been building a value index framework to address that: the Enabling Technology Value Index. The idea is to make each stakeholder’s priorities explicit before the purchase rather than after, so you can see where they line up and where they don’t.
Gautham Prabhakar, MD. Orthopedic Spine Surgeon at Texas Neuro Spine: One of the greatest financial pressures facing physician practices is the growing gap between declining reimbursement and rising costs. Staffing, technology, supplies, malpractice coverage and regulatory requirements are becoming more expensive, making independence increasingly difficult. Some physicians have responded by partnering with hospital systems through professional services agreements, foundation models and other structures that offer greater financial stability and operational support.
Reimbursement can also be misaligned with appropriate care. In spine surgery, smaller, less invasive procedures are often reimbursed relatively poorly compared with larger, more complex operations. Healthcare economics should reward the most appropriate treatment, not simply the most extensive intervention. Despite these pressures, the patient must come first. We must recommend what is right for each individual, regardless of financial incentives. Economics may shape how we structure our practices, but they should never determine how we treat patients. Ultimately, medicine is about taking care of people and doing what is right for them.
Michael Rohan Jr., DO. Orthopedic Spine Surgeon at OrthoEdge (Jacksonville, Fla.): The rise of aggressive prior authorization denials for surgical procedures is having the single biggest financial impact on my practice. Obtaining prior authorization is difficult enough, but even when approved, payment is not guaranteed, and even disbursed funds can be taken back retrospectively. To combat this issue, I am gradually shifting my focus toward personal injury and workers’ compensation cases.
Thomas Scully, MD. Neurosurgeon at Northwest NeuroSpecialists (Tucson, Ariz.): The significant financial impacts on a spine and neurosurgical practice have been spiraling for a few years. In fact, our more than 20 year, very successful private practice, closed 4 years ago and we became hospital employed as a result.
If one is lacking in ancillary revenue models, the solitary practice of neurosurgery and spine, is not sustainable in the current environment. We received a call pay stipend for years. Our former hospital system suddenly, without warning nor discussion, ceased call pay. It had a tremendous impact on our profit and loss ratio. It turned out to be the final nail in our private practice coffin.
The positive aspect is, as an employed surgeon, I do not need to worry as much about the financial impacts. But, this is a double edged sword. Previously, I was very in tune to how expense and revenue changes affected my practice. Now, I really do not even know what I get reimbursed for a laminotomy!
Alex Vaccaro, MD, PhD. President of Rothman Orthopaedics (Philadelphia): Prior authorization, without question. It has become the single largest uncompensated administrative burden on a musculoskeletal practice. Its cost extends beyond the full-time staff dedicated to securing approvals, it delays patient care, disrupts operative schedules and lengthens accounts receivable when cases that were technically approved are later denied.
Our response has been to treat authorization as a managed process rather than a clerical afterthought. We centralized it into a dedicated unit organized by payer rather than by site, embedded medical necessity criteria directly into our EMR templates so that conservative care documentation is captured prospectively at the first visit rather than reconstructed retrospectively, and built denial analytics by payer, CPT and indication, so that we can identify patterns, escalate systematically and bring hard data to the contracting table.
We reserve physician and physician assistant time for peer to peer review rather than letting it fragment the clinical day, and we use our outcomes data to argue appropriateness on the merits. Beyond the practice, we have pushed for gold-carding provisions in payer agreements and supported both state and the federal prior authorization reform initiatives.
Michael Venezia, DO. Orthopedic Spine Surgeon at Florida Orthopaedic Institute (Tampa, Fla.): It comes down to costs rising faster than reimbursement, and that gap gets wider every year. The 2026 fee schedule looked like a raise on paper, but for those of us doing procedures in a facility, the efficiency adjustment and the practice expense cut took most of it back.
We have stopped waiting for that math to improve and started controlling what we can, which means shifting appropriate cases to the ASC, using endoscopic and minimally invasive approaches that lower the total cost of an episode and finding revenue outside the professional fee.
Paul Vessa, MD. Orthopedic Spine Surgeon and Medical Director at New Jersey Spine Institute (Bedminster): The financial pressures of running an independent surgical practice are numerous, including supplies, rent, cleaning and renovation, malpractice premiums, and personnel to support patient care, scheduling and medical records. Prior authorization also requires dedicated staff to spend significant time securing insurer approvals, while billing and collections have become increasingly laborious and costly. Since passage of the No Surprises Act, practices also face the expense of collection services to navigate the independent dispute resolution process.
The greatest pressure, however, is insurers’ refusal to honor IDR awards and payment being withheld for procedures performed months or even years earlier. There is currently no mechanism to enforce timely payment after an IDR award. In New Jersey, Blue Cross Blue Shield is the only insurer employing this strategy, but it represents the overwhelming commercial payer in the market.
Peter Whang, MD. Professor in the Department of Orthopaedics and Rehabilitation at Yale University School of Medicine (New Haven, Conn.): Aside from the other financial pressures that we deal with on a daily basis, which have only continued to increase over the past several years, the proposed reductions in Medicare reimbursement for orthopedic and spinal procedures represent a potentially historic challenge to surgeons and institutions alike.
With our margins already razor-thin, these cuts have the potential to significantly affect the viability of practices that treat this population, such that these patients will inevitably encounter greater difficulties accessing care in the future. It is my hope that appropriate measures will be implemented to prevent or at least delay these changes from taking effect, so that a fair and effective reimbursement system may be developed, which will prove to be more viable long-term.
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.
