As reimbursement tightens and practice costs rise, spine groups are looking beyond professional surgical fees for growth.
Recent strategies include capturing more of the outpatient episode, expanding ancillary services, improving clinic throughput and experimenting with payment models that move practices away from traditional fee-for-service reimbursement.
Here are some of the revenue opportunities spine leaders are pursuing.
The clinic is becoming a revenue engine
For some surgeons, the biggest revenue opportunity starts before a patient ever reaches the operating room.
Michael Verdon, DO, a neurosurgeon and chief medical officer at Dayton (Ohio) Neurologic Associates, said practices can generate more downstream surgical volume by improving how patients are evaluated and triaged in the clinic.
“Guess where I generate all of my revenue from? It’s not in the operating room, it’s from the office,” Dr. Verdon said during Becker’s Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in June.
Dr. Verdon’s practice developed a digital intake tool to identify higher-acuity patients before their appointments. He said the system doubled his personal throughput while allowing him to maintain surgical output even after a competing health system reduced his referral volume by about half. Other practices using the tool have increased surgical throughput by about 10%, he said.
Alex Vaccaro, MD, PhD, president and spine surgeon of Philadelphia-based Rothman Orthopaedics, told Becker’s expanding clinic access can create downstream opportunities for imaging, physical therapy, injections, surgery and other services.
Practices are capturing more of the outpatient episode
ASC ownership remains one of the clearest ways spine groups can participate in revenue beyond the surgeon’s professional fee.
As more spine cases shift from hospitals into outpatient settings, practices with ownership or strategic control over ASCs can participate in the facility economics while gaining more control over scheduling, staffing and supply costs.
Brian Cole, MD, managing partner at Chicago-based Midwest Orthopaedics at Rush, said 70% of the group’s spine cases are now performed in surgery centers.
“If the hospitals don’t play in that space, they will continue to lose facility revenue,” Dr. Cole said.
Other spine leaders see site-of-service control as a margin strategy as professional reimbursement falls. Ernest Braxton, MD, a partner at Vail (Colo.) Summit Orthopaedics and Neurosurgery, said practices protecting their margins are diversifying through ASC ownership and ancillary services.
Ancillary services are becoming more important
Practices are also looking beyond surgery itself to capture more of the care surrounding a patient’s musculoskeletal episode.
Michael Gross, MD, orthopedic director of Union Middlesex Orthopedics in Woodbridge, N.J., said high-performing groups are expanding services including physical therapy, imaging, durable medical equipment and pain management.
“The traditional work RVU model no longer captures the full value of a patient relationship,” Dr. Gross said.
The strategy is increasingly tied to controlling the patient’s care pathway. A patient entering through a spine or orthopedic clinic can require imaging, conservative care, injections, therapy and eventually surgery, giving integrated practices opportunities to capture more of that episode internally.
Dr. Vaccaro said stronger clinic access can support ancillary services and improve the overall financial health of a practice, particularly when advanced practice providers are used to expand access without pulling surgeons away from complex evaluations and surgery.
Cash-pay and hybrid models are gaining attention
Some spine surgeons are reducing their reliance on traditional insurance contracts as reimbursement declines and administrative friction grows.
Peter Derman, MD, an endoscopic and minimally invasive spine surgeon, launched a boutique private-pay practice this year after concluding that the traditional insurance model was making it increasingly difficult to deliver the type of care he wanted. His professional fees are cash pay, while patients can still use insurance for expenses such as facility and anesthesia fees.
Brian Gantwerker, MD, president of The Craniospinal Center of Los Angeles, reached a similar tipping point several years ago and moved away from insurance contracts.
“The tipping point came when each Medicare patient became a net-net loss on each and every office visit,” Dr. Gantwerker said.
Other surgeons see hybrid models as a more practical path. Issada Thongtrangan, MD, an endoscopic and minimally invasive spine surgeon at MicroSpine in Scottsdale, Ariz., said practices could drop low-paying, high-friction contracts while retaining select commercial payers and offering transparent cash bundles for certain outpatient procedures.
Building a cash-pay model, however, creates its own challenges. John Peloza, MD, a spine surgeon with Midwest Orthopedic Spine Specialists in St. Louis, has launched an insurance-free practice, Peloza Spine. He said the concierge model requires greater investment in marketing and patient acquisition because practices can no longer rely on insurer networks to direct patients their way.
Direct contracts are moving revenue closer to physicians
Some physician groups are also looking beyond traditional payer contracts toward direct-to-employer and episode-based arrangements.
Leo Spector, MD, an orthopedic spine surgeon and CEO of Charlotte, N.C.-based OrthoCarolina, has spent years developing value-based and bundled-payment infrastructure. OrthoCarolina has worked with employers and payers on arrangements built around defined pricing and outcomes, including direct-to-employer contracting.
The economics have been particularly successful in joint replacement. OrthoCarolina’s bundled-payment program grew from roughly 80 patients in its first year to an expected 2,000-plus in 2026, while program overhead fell from about 20% to 30% of revenue to less than 10%. Revenue grew roughly tenfold over the same period.
Brian Curtin, MD, an orthopedic surgeon at OrthoCarolina Hip and Knee Center, said the model has changed how he views reimbursement.
“I make more now on a joint in a bundle program than I ever did on fee for service,” Dr. Curtin said.
Spine is more difficult to bundle because procedures and patient complexity vary substantially, and spine-specific bundled models remain less mature. Still, Dr. Spector and other leaders see direct payer and employer relationships as an increasingly important way for physician groups to move more of the economics of an episode closer to the physicians managing it.
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.
