From the Desk of the President
Streamlining Spine Surgical Practice May Optimize Yield and Revenue, But at What Cost?
William Mitchell, MD
President, North American Spine Society Neurosurgical & Spinal Specialists Marlton, NJ
Over the past two decades, a quiet but significant restructuring has taken place across surgical specialties. Driven by efficiency, reimbursement pressure, and a desire to focus on what surgeons do best, many have deliberately narrowed their practice models, seeing only patients who are already deemed surgical candidates. Meanwhile, there is prevalent outsourcing for initial evaluation, workup, and follow-up to advanced practice providers, primary care physicians, or specialist colleagues.
On its face, the logic is compelling. A surgeon’s time is most valuable in the operating room, not in clinic rooms conducting evaluations that may yield no procedure. But a growing number of practice management experts and surgeons themselves are beginning to ask an uncomfortable question — are surgical-only practices inadvertently filtering out patients who would, under a surgeon’s own eye, become operative candidates?
The trend toward procedure-focused surgical practices accelerated in the 2010s as health care systems pushed for value-based care and as relative value unit (RVU) models rewarded procedural volume. Surgeons in orthopedics, general surgery, spine, urology, and ENT began structuring their clinics to maximize OR throughput.
In this model, nurse practitioners, physician assistants, or referring physicians perform the initial consultation. If the patient is deemed a surgical candidate — based on imaging, examination findings, or failed conservative therapy — they are then referred to the surgeon. The surgeon may see the patient once preoperatively, perform the procedure, and discharge follow-up back to the APP or referring provider.
The appeal is undeniable. Clinic schedules become leaner. Surgeons spend more time operating. Revenue per hour of physician time climbs. For high-volume, straightforward cases like routine knee replacements, laparoscopic cholecystectomies, and carpal tunnel releases, the model can function smoothly.
What this model underestimates is the diagnostic and consultative value of the surgeon’s clinical judgment during the evaluation phase itself. Experienced surgeons frequently describe identifying surgical pathology that referring providers or APPs had not recognized or conversely, talking patients out of surgery that less experienced evaluators had endorsed. The surgeon’s examination is not simply a rubber stamp at the end of a workup. It is, in many cases, the workup.
Consider the following illustrative scenario:
A spine surgeon’s APP evaluates a patient with low back pain and radiculopathy. The patient has a moderate disc herniation on MRI but reports only 6 weeks of symptoms. The APP recommends continued conservative management. Had the surgeon personally examined the patient, he/she might have detected subtle foot drop or clinical signs of myelopathy warranting earlier operative intervention.
In this case, a gatekeeper who is not a surgeon is making what is effectively a surgical decision.
Surgical-only practices are only as good as the referral funnels feeding them. When surgeons cede the evaluation process, they cede control over that funnel. Referring providers vary enormously in their familiarity with surgical indications. A primary care physician uncomfortable with surgical referrals may delay sending appropriate patients. An APP operating on a strict protocol may miss nuanced presentations. A competing specialty like interventional pain management, for instance, may capture patients who would have been better served surgically.
The problem is compounded by the fact that surgeons rarely receive feedback on the patients they never saw. A patient evaluated by an APP and counseled toward conservative management does not generate a “missed case” report. The surgeon’s dashboard shows only the cases that reached the OR, not the potential cases filtered out upstream.
This creates a structural blind spot. The surgeon optimizes within the system as designed—high-volume, efficient, procedure-focused—without visibility into the patients who were never presented to the system at all.
While granular data on this phenomenon is limited, adjacent research is instructive. Studies on variation in surgical rates have long documented that the probability of receiving surgery for many conditions such as back pain, knee osteoarthritis, gallstones, and hernias, varies dramatically by geography, health system, and who performs the initial evaluation. Much of this variation is driven by clinical culture and referral patterns, not by patient pathology.
Research on direct-to-surgeon referral models in some orthopedic and spine systems has shown that surgeons evaluating their own new patients identify surgical candidates at higher rates than when patients are pre-screened by non-surgical providers. That’s because they are more sensitive to the physical findings and functional limitations that indicate a patient would benefit from surgery.
Additionally, patient satisfaction and outcome research consistently shows that patients value the opportunity to speak directly with their surgeon early in the process. Patients who feel they were dismissed or “screened out” before reaching the surgeon are more likely to seek second opinions, switch health systems, or delay care, all of which represent lost revenue and continuity for the original practice.
To be fair to the surgical-only model, its defenders make valid points. A surgeon spending clinic time on patients who are clearly not surgical candidates, like those seeking a second opinion on a decision already made, those with non-surgical pathology, or those who are not yet ready to consider surgery, is not a productive use of training or time. In a world of physician shortages, maximizing the surgeon’s procedural output has real value for patients who need timely access to the OR.
Furthermore, well-designed triage systems can be highly accurate. An experienced APP working closely with a surgeon, using clearly defined clinical protocols and with easy escalation pathways, can appropriately identify surgical candidates at high rates while sparing the surgeon unnecessary clinic encounters.
The problem is not the model in concept — it is the model in execution. Too often, the protocols are imprecise, the APPs are under-supervised, and the feedback loops that would allow the system to self-correct are absent.
Progressive surgical practices are beginning to adopt models that capture efficiency without sacrificing case identification. Several strategies have emerged:
- Surgeon oversight of the evaluation process. Rather than delegating initial consultations entirely, some surgeons conduct brief “touch points” — a 5-minute review of the APP’s assessment, a direct examination of uncertain cases, or a weekly case conference to review patients counseled nonoperatively. This preserves efficiency while restoring the surgeon’s diagnostic role.
- Protocol review and refinement. Surgical practices that use triage protocols should audit them regularly, tracking not just operative outcomes but also the downstream fate of patients deemed nonsurgical. Are those patients eventually reaching surgery elsewhere? Answering these questions requires intentional data collection.
- Open-access scheduling for new patients. Some practices have found value in preserving a portion of the surgeon’s clinic schedule for direct new patient consultations. Reserving procedural follow-up and postoperative visits for APPs ensures that a meaningful number of new referrals are seen by the surgeon personally.
- Strengthening referral relationships. Surgeons who invest in education and communication with referring providers tend to receive better-selected referrals. Teaching primary care partners and APPs what a surgical candidate looks like closes the gap between the referral community and the OR.
- Patient-direct access pathways. Some practices now allow patients to self-refer for an initial surgical consultation without requiring a prior nonsurgical workup. While this increases the volume of potentially nonoperative consultations, it ensures that the surgeon makes the determination, not a gatekeeper operating with imperfect information.
The surgical-only practice model represents a rational response to real economic and operational pressures. But in eliminating the surgeon from the evaluation equation, it introduces a subtle yet consequential risk: the systematic under-identification of patients who would benefit from surgical care.
The best surgeons have always understood that the consultation is not overhead, it is clinical practice. The judgment exercised in a 30-minute office encounter, the experienced hand on a patient’s abdomen or knee, the practiced eye reading a patient’s gait or grimace, remain vital. These are not administrative tasks appropriately delegated to the least expensive provider in the room. They are, in many cases, the difference between a patient who receives timely, appropriate surgical care and one who cycles through years of conservative management that was never going to be enough.
Efficiency and access are not inherently at odds. But achieving both requires surgical practices to look honestly at the gatekeeping structures they have built and ask whether those structures are serving patients, or simply protecting the surgeon’s schedule.