A patient sees a primary care physician for back pain, then a physical therapist, then a pain specialist, perhaps a chiropractor, perhaps another pain specialist. There may be injections, an ablation, new imaging and weeks between appointments.
Eventually, the patient reaches a spine surgeon. The surgeon asks questions the patient has already answered, reviews studies someone else already ordered, and reconstructs a story that exists in fragments across multiple offices.
The patient has received care at every step. Yet each step has felt like the beginning.
“There are too many spine programs where people keep feeling like they’re starting over with the next provider,” Ronjon Paul, MD, an orthopedic spine surgeon and chair of spine strategy at Evanston, Ill.-based Endeavor Health, told Becker’s.
Dr. Paul believes the best spine programs of the next decade will be defined less by a single operation, technology or specialist than by their ability to prevent that reset. Patients will enter through one approachable system. They will see the provider best suited to their condition first. If the initial treatment does not work, the next clinician will already understand what happened and why the patient is being handed forward.
No duplicated journey. No clinical scavenger hunt. No expectation that a person in pain must determine whether the problem belongs to a surgeon, physiatrist, pain physician, therapist or another specialist before the health system will help.
“That’s not the patient’s problem to decide,” Dr. Paul said. “Their problem is to have somebody who has their best interests at heart trying to get them better as quickly as possible.”
In the Chicago area, Endeavor is attempting to build this model across a nine-hospital system. Dr. Paul is helping lead the execution of a spine strategy designed to align orthopedic surgeons, neurosurgeons, physiatrists, pain specialists, therapists, chiropractors and primary care physicians.
The premise is simple. The patient should not need to understand the organizational chart to receive coordinated care. Executing it will be much harder.
A spine practice built around not operating
More than 95% of Dr. Paul’s patients receive evidence-based nonsurgical care before an operation is considered. In a specialty where surgical volume can drive substantial revenue, that philosophy appears to create an economic contradiction. Dr. Paul sees it differently.
“I see a spine practice as being not just about surgery, but really being about spine patients,” he said. A program built only around procedures encounters patients at the moment an operation becomes possible. A program built around spine care can meet them earlier, direct them toward appropriate treatment and retain their trust, even when surgery is not the answer.
That distinction changes the economics. Physical therapy, diagnostics, pain management and other nonsurgical services all produce revenue. More importantly, a system that becomes known as a reliable entry point for spine problems can attract a larger population than one organized primarily around surgical referrals. Some of those patients will eventually require an operation. Many will not.
Dr. Paul’s argument is that a health system should build a destination that patients and referring physicians trust enough that the volume arrives naturally. “We just want to do the right things,” he said. “By building a model that does the right things for people, we believe we’re going to have a place where we won’t need to worry about the volume.”
The conservative approach is therefore not the absence of a business strategy. It is the business strategy.
Conservative care may become a competitive advantage
As payment models place greater emphasis on outcomes, cost and the full episode of care, the financial advantages of disciplined patient selection become more visible. Dr. Paul believes insurers already know which physicians tend to operate carefully and which practices generate fewer avoidable costs.
“They have that data,” he said. “They’re already trying to push patients that direction.”
The same is increasingly true of patients. Spine surgery carries a level of fear and uncertainty that distinguishes it from more standardized procedures. Patients may be less focused on the immediate price than on whether the operation will work, how long recovery will take and whether another procedure will follow.
“I think for spine care, it’s more of a quality issue than cost,” Dr. Paul said. Quality, however, has economic consequences. A well-selected patient is more likely to receive the appropriate treatment, experience fewer complications and avoid unnecessary procedures. A faster recovery reduces time away from work. A durable result lowers the likelihood of repeat care.
“Quality inherently does mean cost consciousness because it means fewer procedures, quicker outcomes, lower complications and better quality of life,” he said. That creates an advantage for programs capable of showing that surgery is offered selectively rather than reflexively. In the fee-for-service era, avoiding an operation could look like lost revenue. Under greater accountability for outcomes and total spending, it can look like proof that the system works.
The first appointment may matter more than the operation
In a fragmented system, patients are often left to choose a specialist based on a referral, an internet search, proximity or whichever office can see them first. When the fit is wrong, the patient waits for another appointment and begins again.
Dr. Paul believes a mature spine program should assume responsibility for that uncertainty. The system should identify the most appropriate initial provider, then move the patient quickly when new information points elsewhere. The first clinician does not need to solve every problem. The clinician needs to make progress.
“If they can take care of that patient’s problem quickly and efficiently to their satisfaction early on, then great,” Dr. Paul said. “If not, they can quickly, with proper communication, get them to a different provider.”
The quality of the handoff determines whether the patient experiences that move as advancement or failure. The next clinician should understand the treatments already attempted, the results and the reason for the referral. The patient should know why the transition is happening.
“Every visit makes progress,” Dr. Paul said. “They’re feeling like they’re getting progressively closer to the outcome that they want, whether it’s with surgery or not.” The concept sounds elementary. In many healthcare organizations, it remains radical.
The spine center as a front door
The strongest spine programs may ultimately resemble navigation systems more than collections of specialists. A patient should be able to enter without knowing the exact diagnosis or which physician owns it. The program should then determine the next step.
That requires more than a shared brand or a list of clinicians on a website. It requires scheduling access, clear escalation criteria, aligned medical records and communication that follows the patient.
It also requires leaders to measure different outcomes. Surgical volume will remain important. So will complications, patient-reported outcomes and costs. But the program should also know how long patients wait between providers, how often testing is duplicated, whether referrals reach the appropriate specialist and how many visits occur before a treatment plan is established.
A system can have excellent surgeons and still deliver a poor spine experience. The failure may occur between their offices.
The most important spine practice asset may be trust
AI, navigation platforms and predictive tools will help health systems route patients and standardize pathways. Dr. Paul does not believe software can substitute for the element on which the model ultimately depends: trust among physicians.
A surgeon must trust that a nonsurgical colleague will recognize when the patient’s condition requires an operation. A pain specialist must trust that the surgeon will not operate simply because the patient arrived in a surgical clinic. A therapist must know how to escalate a patient whose symptoms are not progressing as expected. The clinicians receiving the patient must respect the care already delivered rather than beginning from zero.
Dr. Paul saw this work in a previous practice where spine surgeons and pain physicians began working in the same space. The model emerged organically. The physicians knew one another, shared expectations and moved patients among them without treating each referral as the end of one episode and the beginning of another.
“They were already working together and were friends and realized that we were very aligned, marching in the same direction,” he said.
Reproducing that intimacy across a large health system is more complicated. Endeavor’s spine network crosses hospitals, regions and specialties with different workflows, incentives and professional cultures. The organization must build shared pathways without making physicians feel that clinical judgment has been replaced by a corporate protocol.
Why Dr. Paul chose a health system
Dr. Paul spent years in private practice before joining Endeavor. The move reflects a broader reality in orthopedics: creating integrated care at scale requires infrastructure that individual practices may struggle to build alone.
A system can provide capital, technology, data and access across a large physician network. Rather than treating each hospital as an isolated market or constructing only a traditional hub-and-spoke model around one flagship facility, Endeavor has organized leaders with both regional and system responsibilities.
That structure can help translate local needs into one broader strategy. Dr. Paul believes it also enables the organization to make longer-term decisions rather than chasing immediate volume. He wanted to take the patient-centered model he had helped build within a smaller group and expand it using the resources of a larger system.
“The experience that I had at my former group worked very well,” he said. “I thought Endeavor would be the right way to take those concepts and scale them with newer technology and a newer healthcare paradigm.”
Scale can strengthen a care model. It can also dilute it. The risk is that a seamless local culture becomes another centralized program that looks coordinated on an organizational chart but feels disjointed to patients. Dr. Paul believes Endeavor’s leadership gives the project a chance to avoid that outcome.
“If I didn’t think they were driving the bus the right way, I wouldn’t have joined,” he said.
Surgery remains essential
A conservative spine program is not a program designed to avoid surgery at all costs. For patients with instability, progressive neurologic deficits, deformity or other clear indications, delaying an operation can be harmful. The objective is not to place nonsurgical care above surgical care. It is to stop defining the program by that division.
“We may get away from the notion of what’s nonoperative and what’s operative and just talk about spine care overall,” Dr. Paul said. In that model, surgery becomes one component of a larger pathway rather than the destination toward which every patient is pushed.
The surgeon’s role may even become more valuable. By seeing fewer patients without surgical conditions, the surgeon can devote more time to complex cases and those most likely to benefit. Better triage can improve access for patients who genuinely need an operation.
Nonsurgical care protects patients from unnecessary surgery. Navigation also protects surgical patients from unnecessary delay.
The end of the restart
Endeavor’s strategy remains in its early stages. The system has completed the planning phase and formed an execution committee. The difficult work, aligning clinicians, spaces, pathways and patient access across the organization, is only beginning.
The model will be tested by the same forces that fragment care elsewhere: local habits, scheduling constraints, competing incentives and the difficulty of changing how physicians have worked for years.
But the problem it is trying to solve is immediate. Spine patients are moving through healthcare systems that often ask them to coordinate their own care while in pain, frightened and uncertain about whether they will recover.
They do not need every clinician to provide the same treatment. They need every clinician to understand the same journey. The spine program of the future will not be the one that performs the most operations or owns the newest technology. It will be the one where the patient never has to begin again.
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.