Growth can be a natural reward for a successful physician-owned practice. It could also be the force most likely to erode what made the practice attractive in the first place: physicians’ control over how they work.
Charlotte, N.C.-based OrthoCarolina is testing that balance. Physician-owned since 1922 and operating more than 40 locations, the practice plans to grow its ASC capacity from four operating rooms to 10 by expanding its Matthews, N.C., center from two rooms to four and building a new, wholly owned, four-room center in Charlotte’s Steele Creek area, expected to open by the end of 2027.
The push follows changes to North Carolina’s certificate-of-need laws, while funding for the expansion came in large part from OrthoCarolina’s sale of its physical therapy business to PT Solutions in January 2025.
Leo Spector, MD, an orthopedic spine surgeon who became OrthoCarolina’s CEO in January 2024, argues that the debate over physician independence often starts with the wrong definition. Unless a physician practices solo, he said, full independence doesn’t exist. Partners bring shared accountability, and every decision has to take them into account. In his view, autonomy is a spectrum, not a yes-or-no question.
He knows the far end of that spectrum firsthand. His late father spent most of his career as a solo practitioner and could run his office however he chose within the law, down to how many clinical assistants he hired.
“That was true independence, true autonomy,” Dr. Spector said.
OrthoCarolina, which employs more than 300 practitioners in the Charlotte area, can’t operate that way. As the practice has grown, Dr. Spector said, the aim has been to keep the advantages of independent practice while capturing the economies of scale that come with size, knowing no arrangement delivers both perfectly.
“I think there’s the old quote: ‘There’s no solutions, just trade-offs,'” he said. “So you’re always making trade-offs.”
What makes those trade-offs workable, Dr. Spector said, is governance, and he credits the practice’s founders and its evolution over time rather than his own tenure. OrthoCarolina’s structure runs from its shareholders to a board of partners to an elected executive committee, and it defines how physicians work with administration, the side Dr. Spector now sits on as CEO.
“That governance structure, I think, is what allows us to be able to scale, have that uniformity while still allowing for enough independence and autonomy to make it feel not employed,” he said.
The arrangement asks physicians to hold two roles at once. OrthoCarolina’s physicians are shareholders in the practice and also its employees, and Dr. Spector tells his partners the organization has to work for them in both capacities: delivering what an owner would want from a business while remaining a good place to work.
In practice, that means a defined route for every investment. Dr. Spector offered the example of physicians who want a new X-ray machine so they can perform more procedures in the office. Instead of buying one themselves, they go to administration, which builds the business case and pro forma. The proposal then goes to the finance committee, where physician peers review the investment and whether it is profitable for the group and good for the individual. From there, the operations committee weighs how the machine would affect patient care and the practice’s staff.
“Ultimately, it comes up to an executive committee that is their physician peers that they’ve elected, who gets to make a final decision based on having all that information,” Dr. Spector said.
The alternative, he said, is administration spending physicians’ money and placing equipment in their clinics without asking how it would change their workflow or their patients’ care. The committee path rules out both that scenario and a physician acting alone, and replaces them with a process every partner knows.
Dr. Spector made a broader case for continuity at a recent town hall with OrthoCarolina’s roughly 1,500 to 1,600 employees, held amid uncertainty across healthcare. Whatever shifts around the organization, he told them, its mission, vision and values will hold, even if the way it carries them out has to change.
“We have to evolve, or we get left behind. But it doesn’t mean we have to leave behind our why, our mission, our vision, our values,” he said.
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