From the decline of private practice to the 'minefield of prior authorization': The most dangerous trends in spine, orthopedics


From ongoing fights with insurance companies to scope of practice expansions for non-spine and orthopedic trained physicians, 25 physicians told Becker's the trends that they think are the most dangerous to spine and orthopedics right now. 

The executives featured in this article are all speaking at Becker's 2024 ASC conferences. This includes Becker's 21st Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference which is set for June 19-22 at the Swissotel in Chicago. This also includes Becker's 30th Annual The Business and Operations of ASCs, which is set for Oct. 30-Nov. 2 at the Hyatt Regency in Chicago.

If you work at an ASC and would like to join as a speaker, contact Claire Wallace at

As part of an ongoing series, Becker's is talking to healthcare leaders who will speak at our events. The following are answers from our speakers.

Question: What is the most dangerous trend in spine and orthopedics right now? 

Alfonso Garcia, MD. Spine Surgeon at Espalda Saludable (Tijuana, Mexico): There's always a "dangerous trend" when a new technique or implant is introduced as a novel and promising solution to an old problem. I've been adding endoscopic approaches to my practice since 2011, and have been an avid advocate since then. In Mexico, there's been a recent surge toward incorporating endoscopic spine surgery by many undertrained surgeons. This trend, as it has always been happening throughout the evolution of better and less invasive spine surgical procedures, will experience a short rise in early adopters complications. With time and improvements in training programs we will see more stable and predictable results. 

Brett I. Shore, MD. Orthopedic Surgeon at DISC Sports & Spine Center (Newport Beach, Calif.): The most dangerous trend in spine and orthopedics right now is the decrease in physician reimbursement for visits and procedures. This trend will lead to surgeons seeing larger numbers of patients in the office, as well as longer, more densely-packed surgical days just to make up for the loss in revenue that is occurring in an otherwise inflationary environment. As a result, patients will feel less "cared for" during these shorter visits (increasing the risk of malpractice claims), and surgeons will reach levels of burnout that are dangerous and damaging to the fields of spine surgery and orthopedics overall.

Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: There are two dangerous trends in spine currently. First is the continued push of device manufacturers to put pedicle screw-type devices into the hands of non-spine surgeons. Multiple organizations, including the Congress of Neurological Surgeons, American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons put out a joint position statement stating, unequivocally, that spine surgery and specifically fusions should only be done by surgeons. There have been several concerning posts on LinkedIn and some other social media sites with non-surgeons showcasing them placing interspinous devices and devices supported by pedicle screws. It is beyond the pale. If you want to put in pedicle screws, do the appropriate residency and fellowship. There are no shortcuts, and patients should not suffer aspirational greed and clinical gaslighting. Second is decreasing reimbursements. The desire for CMS and ultimately HHS to drive down the number of surgeries performed, despite clinical decision-making of experienced spine surgeons and their clinical acumen, by decreasing payments for complex surgery and their management will result in lack of access to trained spine surgeons for the rural and under-insured. I am not sure ultimately if CMS can hear anything outside of their opaque silo, but the public needs to tell them that if surgeons leave areas, the patients will be even more at risk. 

Dean Karahalios, MD. Neurosurgeon at Advocate Medical Group (Chicago): We as clinicians find ourselves navigating a minefield of threats that have insidiously and progressively marginalized the therapeutic relationship between us and our patients. The most dangerous is the intrusion of the third party payer. This is nothing new, but I worry that we have become too complacent and now find ourselves in a state of learned helplessness where onerous, arbitrary and perpetually changing rules of engagement justifying denials of care are tolerated as a fait accompli. We have naturally accepted the value proposition of quality over cost, but are we willing to concede the role of gatekeeper to a middleman that brings little if anything substantive to the table and yet extracts ever increasing resources. We have naturally accepted the scrutiny in conflicts of interest within our industry but are we willing to ignore the glaring inverse relationship between third party payer denials and corporate profits. We should not assume that third party payers will naturally follow suit in accepting what is in the best interest of our patients. Perhaps an increased degree of regulatory oversight that is on par with that directed at our specialty may free us to rekindle the therapeutic relationship with our patients. 

Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: One not specific to orthopedics is direct marketing by companies to consumers. Patients come in with certain expectations, regardless if they are candidates for that particular medication or procedure. We often have to unravel these hopes. I also see the decline of the private practitioner/group as a danger. Competition is good in any business. In medicine, it breeds good patient care and good outcomes. In a small private practice, these two metrics combined with office efficiency are our lifeline. We need happy, healthy patients to "advertise" our practice.

Eric Mehlberg, MD. Pain Management Specialist: Without a doubt the most dangerous trend in spine-adjacent fields is the minefield of prior authorization (which consumes endless time and phone calls with no guarantee of payment) and the dubious medical literature the insurance companies cite to justify harming their customers.

Eric Wieser, MD. President of AOA Orthopedic Specialists (Arlington, Texas): I believe the biggest trend in orthopedics and spine that will prove detrimental to the surgeon's daily practice is the hospital system employed model for surgeons. Most of these models prohibit surgeon ownership in any of the ancillary revenue streams that often substantially supplement an orthopedists' total compensation package. Furthermore, the administrative pressures in the clinical practice implemented by the system is often without surgeon approval or guidance. This model creates a division between the surgeon leaders and practice administrators that ultimately decreases surgeon job satisfaction and productivity. I do not see this hospital-employed model sustainable long term without major modifications to most of the current surgeon-hospital arrangements.

Ernest Braxton, MD. Neurosurgeon at Vail (Colo.) Summit Orthopaedics and Neurosurgery: One potentially dangerous trend in spine and orthopedics is the overutilization of certain surgical procedures, such as spinal fusion, which may not always be necessary or beneficial for patients. Overutilization can lead to unnecessary risks, complications and healthcare costs. This trend can be exacerbated by the concept of moral hazard, where the availability of insurance coverage or financial incentives may influence surgeons to recommend or perform surgeries that may not be medically necessary. To address this trend, there is a growing emphasis on evidence-based medicine, shared decision-making and professional guidelines among spine surgeons to ensure that surgical interventions are used judiciously and appropriately. By promoting a more conservative and selective approach to surgery, spine surgeons can help mitigate the risks associated with overutilization and ensure that patients receive the most appropriate and effective care for their condition.

James Chen, MD. Orthopedic surgeon at DISC Sports & Spine Center (Newport Beach, Calif.): The increasing disparity in the access to quality timely care, especially in elective surgical subspecialties, is a dangerous trend that we have to control. With decreasing reimbursements and increasing costs, coupled with the higher demand of an aging population, my concern is that access to care for a large portion of our population will be an increasing issue if this trend continues. Appropriate alignment of accurately defined "value-based care" is crucial to be able to continue to provide timely access to care and minimize the cost burden. 

Jeffrey Moore, MD. Orthopedic Spine Surgeon at SonoSpine (Oklahoma City): Emerging technology such as navigation or robotics has the potential to be a wonderful tool for surgeons. However, there is a dangerous trend of overreliance on this technology by young surgeons. This could be surgeon driven, or could be related to reliance on it in training programs. We as spine surgeons should be able to do most cases with fluoroscopy only. Canceling cases due to navigation or robotic machinery being faulty should only happen in rare instances. We need to be careful to not let this tool become a crutch. The use of interspinous devices by pain management physicians in patients who would benefit from true spine surgery is a dangerous trend. In specific instances, patients may benefit from these devices, if they are unable to tolerate spinal surgery. However, utilization of these devices as a primary way to treat spondylolisthesis and other pathologies, without first having an evaluation by a fellowship-trained spine surgeon, is a dangerous trend.

John Prunskis, MD. CEO and Medical Director of the Illinois Pain & Spine Institute (Elgin): A dangerous trend in spine and interventional pain management is insurance companies denying or delaying approval for necessary procedures for patients. The profits of insurance companies are skyrocketing, and patients are being adversely affected by their withholding of necessary care. This is, among other adverse issues, fueling the opioid crisis as these patients with painful conditions needing procedures or surgeries frequently need to have their pain masked frequently with opioid narcotics until they get the needed procedure or surgery.

Leon Anijar, MD. Co-Founder and Chief Medical Officer at Flagler Health (Saint Augustine, Fla.): I think the most dangerous trend in orthopedics and spine surgery is the loss of physician autonomy and growth of large health systems that anonymize the patient-physician relationship. Doctors will be replaced by healthcare brands in the next 10 to 20 years, leading patients to engage with Baptist, Memorial or Mt. Sinai as opposed to Dr. Jones or Dr. Smith. 

Louis Nel, MD. Neuro-Spine Surgeon at Spine Africa (Pretoria, South Africa): Surgeons trying to stay in front of the wave of endoscopic spine surgery, without following the learning curve. Although endoscopic spine surgery is addressing the same pathology, the anatomy has to be re-evaluated, and the learning curve is measured in years to master. Proper fellowship and mentorship are needed and, if coupled with navigation, can flatten and shorten the learning curve hugely. 

Maahir Haque, MD. Surgeon at Spine Group Orlando (Celebration, Fla.): The most dangerous trend in spine surgery today is the utilization of increasingly complicated and resource-intensive solutions as implant companies seek to differentiate themselves in the marketplace. There is less investment in the elegant and simple solution. A distinct and particularly inefficient example of this is the investment in bespoke positioning solutions for procedures like lateral and prone lateral interbody fusions. The bolstering systems are a branding exercise and unnecessary for those procedures — they are designed and marketed for the purpose of differentiation rather than for patient benefit. 

Michael D. Burdi, MD. Partner at Community Orthopedic Medical Group (Mission Viejo, Calif.): Declining reimbursement is reaching a breakpoint in areas of orthopedics such as total joints and spine. If these trends continue, care will be compromised. Inflation is rapidly outpacing reimbursement. Risk stratification will seep in to affect access to care to higher risk patients.

Mick Perez-Cruet, MD. Professor and Vice Chair of Neurosurgery at Oakland University William Beaumont School of Medicine (Rochester, Minn.): The most dangerous trend in spine and orthopedics is the decline in physician reimbursement. This trend can lead to physician practice failure as costs continue to increase. Unintended consequences are increases in unnecessary procedures or services to offset declining reimbursement to cover cost. In the end, declining reimbursement leads to poor patient care and access to medical specialists. 

Nolan Wessell, MD. Orthopedic Surgeon at UCHealth (Aurora, Colo.): In my eyes, there are many dangerous trends facing orthopedics and spine care. Obviously, practices will continue to battle further declines in reimbursement that will present significant challenges, especially for those practices that haven't optimized their ancillary revenue streams. I also fear the continued expansion of private equity investments in healthcare. Collaboration with PE may appeal to senior partners in a practice, but it significantly hinders the ability to attract and retain younger surgeons as they fear that their investment is diluted and may lack value when they reach retirement age 25 to 30 years in the future. Practices and surgeons must continue to leverage their value to the hospital in an effort to gain the support they need to continue to provide high quality patient care. 

Peter Passias, MD. Orthopedic and Spine Surgeon at NYU Langone Health (New York City): Given the increasing rapidity of expanding technology and techniques, one major issue we need to address in spine surgery is the rapid adaptation of novel techniques and technology just based on novelty, without adequate properly designed and honest research and training to support the optimal usage of these technologies. This is true for all elements of spinal surgery, but in particular lesser invasive procedures, which may be construed as having less regulation due to inherently lower risk. As many of these novel technologies represent major advances in our field, the lack of success of a minority of these should not take credit away or deter true advancements in the field. 

Reuben Gobezie, MD. Director of the Cleveland Shoulder Institute and Regen Orthopedics and CEO of Genie Health (Mayfield Heights, Ohio): The most dangerous trend as pertains to spine and orthopedics in the ASC presently are:

1. The increasing costs of implant pricing whilst a decrease in reimbursement is consistently being realized. Innovation will suffer in the U.S. healthcare system and facilities are not allowed, due to archaic Medicare rules, to balance bill patients for the costs of new/cutting-edge implants. This fact reduces the patients' ability to exercise choice in what implants [what quality] are used in their surgeries. The insurance companies and Medicare rules force ASCs to decide between quality of implants and business viability.

2. The delays in payments by insurance companies, along with a dramatic increase in denials for surgical services and the increasingly arduous processes for prior authorization of procedures. The reality is that many insurance companies are delaying payments for services rendered and are denying portions of the services using "arbitrary law." The appeals process is costly to the ASCs and, in effect, results in an ever-increasing amount of "free care" in the system. We need to allow balance billing for implants so that patients have the ability to purchase more innovative implants without asking the ASC to pay for it whilst the insurance companies pay less. The fact is that insurance premiums and patient responsibility continue to rise and increase, respectively, and the payments from insurers to private practices continues to decrease.

3. Insurance companies have contracts with ASCs that do not enable ASCs to price the massive increase in costs associated with staffing both the OR nurses and anesthesia. 

Salvador Portugal, DO. Interventional Spine & Sports Medicine Specialist at NYU Langone Orthopedic Center (New York City): What we have is a two-part problem. Some follow the philosophy that the majority of low back pain is nonspecific and should be treated with cognitive behavioral therapy. However, there are many specific identifiable causes of low back pain with specific corresponding treatments with validated outcomes, including mechanical diagnosis and treatment (MDT) physical therapy, fluoroscopic-guided spine interventions (e.g., epidural steroid injections and medial branch nerve radiofrequency ablation), and surgery for radiculopathy. That said, there are many emerging technologies gaining popularity that show promise in treating specific causes of low back pain via regenerative medicine, basivertebral nerve ablation, and neuromodulation. However, the optimal candidate for these procedures still remains unclear. 

Samer Hasan, MD, PhD. Department Chair of Orthopedic Surgery at the Jewish Hospital (Cincinnati): The most dangerous U.S. trend in spine and orthopedics is the never-ending cycle of declining reimbursement to both hospitals and surgeons, often seemingly in direct response to improved efficiencies and productivity. Reimbursements to surgeons for joint replacement surgery and to ASCs for outpatient total joint replacement are two glaring examples, but there are many others. One recent study presented at this year's American Academy of Orthopaedic Surgeons annual meeting projects that surgeons will get reimbursed less than minimum wage for primary total joint replacement by 2030. This downward spiral impedes the adoption of new technologies that might otherwise improve and optimize patient care, pressures surgeons to change their practices or exit the specialty altogether, and stifles the recruitment of new orthopedic surgeons. In the end, none of this helps our patients.

Shane Nho, MD. Co-Director of the Division of Sports Medicine at Midwest Orthopaedics at Rush (Chicago): With cases moving to the outpatient setting, the surgical team needs to coordinate any medical concerns with the anesthesia team to ensure that the right patients are having surgery in the ASC environment. Hospitals will still need to be necessary for surgeons who have patients with medical comorbidities.

Tan Chen, MD. Assistant Professor of Orthopedic Surgery at Geisinger Commonwealth School of Medicine (Scranton, Pa.): There is an increasing number of nonsurgical and pain management physicians who have started performing spinal instrumentation. Without formal spine surgery training and understanding the indications and management of complications, this is extremely dangerous for patients, physicians and the public perception of spine surgery. 

Thomas Schuler, MD. Spine Surgeon and Founder at Virginia Spine Institute (Reston): The most dangerous trend in spinal healthcare is the continued denial of care for patients by insurance companies. People who have failed nonoperative treatment and that are unable to live the functional quality of life that they could if interventions were allowed, are continuing to suffer because of denied care. Neck and back pain are the leading cause of disability in the U.S. and world. Many more people are working impaired with decreased productivity. Over a third of our population has significant neck and/or back pain annually. Treatments exist that can restore lives and enable people to regain function, but denied services impair their recovery. Access to the best treatments needs to be streamlined and reasonable. Today it is not and physicians are wasting hours fighting on behalf of their patients to obtain care for them, often unsuccessfully.

Zoher Ghogawala, MD. Chair of the Department of Neurosurgery at Lahey Hospital and Medical Center (Burlington, Mass.): Delays in preauthorization can result in harm to patients and frustration for spine healthcare providers. The preauthorization process for spinal interventions is getting more difficult and more opaque. It is a growing concern across the country.

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