One spine surgeon estimates he generated $20 million in annual revenue for a trauma center. But as more spine procedures become candidates for outpatient surgery, that figure illustrates a growing tension between surgeons seeking greater flexibility and hospitals with financial incentives to retain cases.
“Through different sources, I found out I generated $20 million in revenue for the trauma center I work at in one year,” Lali Sekhon, MD, PhD, a spine neurosurgeon at Reno (Nev.) Orthopedic Center, told Becker’s. “They don’t want to lose that, and that is going to be a big challenge.”
The conflict over surgical volume is one of several fault lines between spine surgeons and hospitals. Across recent Becker’s interviews, surgeons have described competing priorities involving complex cases, technology investments, productivity expectations and physician autonomy.
The complex-case divide
As lower-acuity spine procedures migrate to ASCs, hospitals may be left with a greater concentration of expensive deformity corrections, complex revisions and other resource-intensive operations.
Keven Burns, MD, an orthopedic spine surgeon at the Scottsdale-based Spine Institute of Arizona, recently told Becker’s that advances in minimally invasive surgery are expanding treatment options for older patients with complex spinal conditions. But those capabilities are developing alongside mounting financial pressures.
“We have awesome technology right now, but financially, can we even implement it?” Dr. Burns said. He questioned whether reimbursement pressures could eventually make hospitals more selective about which complex procedures they can financially support, creating tension between expanding surgical capabilities and maintaining sustainable programs.
The fight over where surgery happens
The migration of spine procedures to outpatient settings creates another potential divide over who controls surgical volume. For surgeons, ASCs can offer greater scheduling flexibility, operational efficiency and ownership opportunities. Hospitals, meanwhile, have financial incentives to retain procedures within their systems.
Dr. Sekhon argued that one-level lumbar fusions are increasingly appropriate for outpatient settings, but financial incentives and reimbursement barriers continue to slow the transition.
The disagreement extends beyond the site of care. Facility ownership, revenue distribution and operating room access can all influence the relationship between hospitals and their surgeons.
The technology investment divide
Robotics, navigation and other surgical technologies offer new capabilities, but their financial value remains a subject of debate.
Michael Gallizzi, MD, a robotic and endoscopic spine surgeon at The Steadman Clinic in Vail, Colo., told Becker’s in June that hospitals can invest heavily in technology without achieving the expected returns if they underestimate the training, workflow changes and institutional commitment required.
“The biggest thing I’ve noticed throughout my career is there are dabblers and there are doers,” Dr. Gallizzi said.
Other surgeons question whether the technology justifies its cost.
“Robotics has yet to show any ROI in spinal surgery,” Stephen Banco, MD, founder of Keystone Spine & Pain Management Center in Wyomissing, Pa., told Becker’s in December. The differing perspectives illustrate the challenge for hospitals balancing surgeons’ interest in new capabilities with capital costs, utilization and financial returns.
When productivity means different things
Disagreements also arise over how hospitals and surgeons define productivity.
Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, told Becker’s in July that increasing clinic access and patient throughput often generates resistance among spine and orthopedic surgeons.
Health system leaders may want physicians to add clinic sessions, shorten appointments or accommodate more same-day visits to increase access and generate downstream revenue. Surgeons, however, may view those demands as taking time away from complex evaluations and surgery.
“The resistance is usually not about working harder; it’s about whether the additional clinic work creates value for both the surgeon and the organization,” Dr. Vaccaro said. He suggested that stronger advanced practice provider teams and greater transparency about the financial benefits of expanded access could help align surgeons’ priorities with organizational goals.
The question of who controls the practice
Hospital employment can provide financial stability, administrative support and access to infrastructure. But it can also shift decisions about staffing, technology and scheduling away from physicians.
In an August Becker’s discussion, spine and orthopedic surgeons questioned whether the distinction between hospital employment and private equity ownership matters as much as the control physicians retain over their practices.
Philip Louie, MD, a spine surgeon at the University of Washington in Seattle, said health systems may retain authority over implant selection, operating room block time and service line priorities.
Other physicians emphasized the advantages of hospital employment, including research infrastructure, financial predictability and multidisciplinary resources. The central issue is not necessarily whether surgeons work for hospitals, but how much influence they retain over clinical and operational decisions.
Where alignment becomes essential
The tensions between spine surgeons and hospitals are unlikely to disappear as more procedures move to outpatient settings and reimbursement pressures intensify.
For surgeons, the stakes center on maintaining clinical autonomy and access to the resources needed to treat patients. For hospitals, they involve balancing those priorities against rising costs and financial sustainability.
The question is whether both sides can reconcile those competing demands before financial considerations begin to dictate which spine procedures are performed, where they take place and who gets to make those decisions.
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.
