Spine surgeons may determine when an operation is necessary, but they do not necessarily control the financial decisions surrounding it.
Insurers influence which procedures are covered and whether claims are paid. Hospitals and ASCs receive facility revenue. Practice owners and administrators make decisions about staffing, investments and contracts. Meanwhile, federal payment models are introducing new financial accountability for hospitals and selected specialists.
The division of financial authority is raising questions among spine leaders about whether physicians have enough influence over the costs and revenue associated with the care they deliver.
“Too many of them push the risk onto the surgeon while the hospital, the payer and the device company keep the savings,” Richard Menger, MD, vice chair of neurosurgery and director of the USA Spine Institute at the University of South Alabama in Mobile, told Becker’s.
Recent Becker’s reporting highlights four areas where spine surgeons say financial decision-making power is shifting.
Payers: Who decides whether care gets paid?
For spine surgeons, insurer requirements can influence not only when patients receive care but also the resources practices devote to securing reimbursement.
Kasra Ahmadinia, MD, director of minimally invasive spine surgery at Advanced Orthopedics of Oklahoma in Tulsa, described a patient whose path to surgery was delayed nearly six months by insurer requirements. After the patient completed physical therapy and injections, the insurer required additional treatment and later determined that the earlier physical therapy was outdated, according to Dr. Ahmadinia.
“The goalposts are moved all the time,” he told Becker’s. Dr. Ahmadinia questioned why physicians must repeatedly defend treatment decisions to organizations that are not directly involved in patients’ daily care.
The concerns extend to reimbursement after surgery. Brandon Hirsch, MD, an orthopedic spine surgeon at DISC Sports and Spine Center in Newport Beach, Calif., has described instances in which insurers denied payment for procedures that had previously received authorization.
In a separate Becker’s report, 73% of 187 respondents to an informal LinkedIn poll identified insurer requirements as the greatest threat to spine surgeons’ control over patient care. The respondents were not independently verified as spine surgeons.
Together, the accounts illustrate the influence physicians say insurers exercise over treatment timelines and payment, even when surgeons remain responsible for clinical decisions.
Facility owners: Who benefits when surgery moves outpatient?
As spine procedures shift toward outpatient settings, surgeons are increasingly weighing whether they should have an ownership stake in the facilities where they operate. Ramin Raiszadeh, MD, an orthopedic spine surgeon at the Spine and Brain Institute of San Diego, identified the choice between hospitals, independent ASCs and joint venture ASCs as one of the hardest decisions facing spine surgeons in 2027.
In a recent Becker’s discussion, Dr. Raiszadeh argued that surgeons without facility ownership could lose income and influence as more procedures move outpatient. He advocated for joint ventures involving hospitals, ASC management companies and surgeon investors.
“The key is getting the terms right, so surgeons have real ownership and a real voice in how the center is run,” he said.
Under the arrangement he described, hospitals would contribute capital and payer relationships, management companies would oversee operations, and surgeons would bring surgical volume while participating in facility revenue.
His argument reflects a distinction between professional reimbursement for performing an operation and the separate revenue generated by the facility where it takes place. For surgeons, Dr. Raiszadeh suggested, the financial stakes increasingly depend on whether they participate in both.
Practice ownership: Who controls the decisions behind the revenue?
The debate over financial control extends beyond whether spine surgeons are independent, hospital-employed or affiliated with private equity. Cory Calendine, MD, an orthopedic surgeon at Bone and Joint Institute of Tennessee in Franklin, argued that physician influence depends heavily on governance.
“Who has a voice in the decisions?” he asked in a Becker’s discussion of private equity and health system ownership. Dr. Calendine said physicians should have meaningful input into clinical operations, staffing, technology adoption and strategic direction, regardless of the organization’s ownership model.
Dr. Hirsch offered a related perspective in the same discussion. He said surgeons who join hospital systems or private equity-backed platforms often transfer responsibility for payer contracting, staffing, billing, collections and other business operations to the larger organization.
Dr. Hirsch described those responsibilities as important sources of autonomy for independent practices, while noting that health systems and private equity-backed groups may create different pressures involving referrals, facilities and compensation.
For physicians seeking to remain independent, the financial decisions can be substantial.
Thomas Fondren, CEO of Advanced Orthopedics of Oklahoma in Tulsa, identified payer strategy and the cost of maintaining independence as major challenges for 2027. Mr. Fondren said independent groups may need to reconsider unfavorable payer contracts, pursue direct employer relationships and invest in ASCs, physical therapy, technology and other services.
Julian Price, MD, an orthopedic spine surgeon at Athens (Ga.) Orthopedic Clinic, similarly pointed to mergers, joint ventures, clinically integrated networks and payer relationships as consequential decisions for independent practices.
Their perspectives underscore a trade-off facing spine groups: Maintaining greater control over business decisions can require additional investment, while partnering with larger organizations can change who makes those decisions.
Medicare: Who carries the financial risk?
CMS is expanding financial accountability through payment models that tie reimbursement to cost and quality. Under the Transforming Episode Accountability Model, participating hospitals are accountable for qualifying surgical episodes, including spinal fusion. The Ambulatory Specialty Model will evaluate selected specialists treating conditions including low back pain beginning in 2027, with payment adjustments starting in 2029.
“The hardest decision in 2027 is whether to own the whole spine episode, including the nonsurgical pathway, or keep owning only the operation,” Michael Verdon, DO, a neurosurgeon and chief medical officer of Dayton (Ohio) Neurologic Associates, told Becker’s.
But taking greater responsibility for the cost of care also raises questions about who bears the financial risk, and who benefits from the savings.
Dr. Menger warned that value-based payment models can shift financial risk to surgeons while hospitals, payers and device companies retain the savings. He argued that surgeons need a meaningful share of savings, protection from costs outside their control and a role in developing performance measures.
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.
