Ten physician leaders joined Becker’s to discuss whether the independent model is breaking or just changing form. The answers were more nuanced than a simple obituary, but most agree the bar has become increasingly higher.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Is the independent physician model breaking, or just changing form?
Justin Bundy, MD. Spine Specialist and Orthopedic Surgeon at Georgia Carolina Orthopedics (Augusta, Ga.): The independent physician model in orthopedic surgery and spine surgery is not disappearing so much as evolving into a more scaled and structurally sophisticated form. While traditional small private practices are under pressure from declining reimbursement, administrative burden, and limited payer leverage, orthopedics remains more resilient than most specialties due to its procedural revenue base and ability to capture ancillary income streams. The real shift is away from fragmented, fee-for-service–dependent groups toward larger, platform-oriented practices that integrate ASC ownership, physical therapy, imaging and advanced contracting strategies. In this environment, independence is increasingly defined not by solo practice, but by physician-led organizations with the size, infrastructure and capital to compete. As a result, the future of independent orthopedics is less about survival versus employment and more about whether groups can achieve the scale and operational sophistication required to remain economically and clinically autonomous.
Benjamin Burch, MD. Orthopedic Surgeon at Specialty Orthopaedics (Gainesville, Ga.): The independent physician model in spine surgery is not breaking — it is evolving into more sustainable, often hybrid forms. Traditional, small-group, fully physician-owned practices have declined sharply, driven by falling Medicare reimbursements, rising overhead, and administrative burdens. Yet in orthopedics and spine, independence remains relatively strong (around 54% in some reports), primarily fueled by ASC ownership, ancillary revenue and procedural volume shifting to outpatient.
A newer “third-option” model — physician-led platforms integrating clinic, ASC, imaging and shared infrastructure — preserve clinical autonomy and ownership stakes while providing scale and reduced administrative load.
Successful independent or semi-independent spine surgeons now must master healthcare economics, payer negotiation, data analytics and minimally invasive/outpatient strategies to thrive amid ongoing pressures. Overall, the core of physician-led decision-making and entrepreneurial control is adapting and proving resilient rather than disappearing.
Matt Cronin. Founder and CEO at Somnus Technologies (Denver): I’d say it’s changing form, not breaking. The pressures are real — rising overhead, payer complexity, technology costs — but independent physicians are adapting through microgroups, shared services organizations, and clinically integrated networks that preserve autonomy while distributing the burden. The desire for independence hasn’t gone away; what’s shifting is the definition. It’s less about going it alone and more about maintaining clinical authority within a sustainable structure. The model isn’t dying — it’s growing up.
Edward DelSole, MD. Orthopedic Spine Surgeon of Keystone Spine & Pain Management Center (Wyomissing, Pa.): The romantic version of independent practice is dead. Solo physicians operating outside payer contracts, setting their own fees, building a practice on referral relationships alone — that model isn’t changing, it’s gone.
What’s surviving is something harder. Independent practice today requires the operational sophistication of a small business, the compliance infrastructure of a mid-size enterprise, and the data fluency of a health system — with none of the institutional support. The physicians making it work aren’t just good surgeons. They’re running revenue cycle operations, navigating prior auth gauntlets, negotiating device contracts, and building technology stacks from scratch.
That is a steep Darwinian filter. If your intention is to see patients, do surgery, and go golf by 3 p.m you will be selected out.
The honest concern isn’t that independence is dying — it’s that the barrier to sustaining it is now so high that only a narrow cohort can clear it. Who is that cohort? Physicians with deep motivation, strong professional networks, and healthy entrepreneurial instincts will be able to thrive. This has real implications for patient access, specialty diversity and long-term market structure that nobody in health policy is taking seriously enough.
Megan Friedman, DO. Chair and Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): The independent physician model is not breaking, it is evolving. The shift is away from purely productivity-based compensation toward coverage-based structures that reflect the operational reality of today’s environment. Hospitals and ASCs still rely on physician-led anesthesia groups for reliability, flexibility and leadership, but expectations have shifted with workforce constraints and increasing acuity in outpatient settings. The groups that will succeed are those that operate as true partners in perioperative care, aligning coverage with demand and contributing to system-level efficiency, rather than functioning as a transactional staffing service.
Michael Gagnon. Founder and CEO of the Academic Orthopaedic Consortium and Chief Administrative Officer- Emeritus at Duke University Orthopaedics (Durham, N.C.): It is not breaking, it is evolving. What we are seeing is a structural shift driven by scale, complexity, and economics. Independent models are becoming increasingly difficult to sustain in isolation due to declining reimbursement, rising administrative burden, and the capital requirements needed to compete in today’s healthcare environment. However, independence is not disappearing, it is being redefined.
Physicians are moving into hybrid models that preserve elements of independence while leveraging the infrastructure of larger organizations. This includes:
- Alignment with health systems
- Participation in ambulatory surgery centers
- Co-management and service line agreements
- Platform-based or networked group structures
In orthopaedics specifically, private practices that have access to ancillary revenue streams, such as ASCs and musculoskeletal institutes, remain highly viable and, in many cases, very strong financially. The key distinction is that success now depends less on being fully independent and more on being strategically aligned.
In that sense, the future is not about independence versus employment — it is about integration with optionality. Physicians and groups that can align with health systems while maintaining some level of economic participation and governance will be best positioned to succeed.
David Kaye, MD. Spine Surgeon at Rothman Orthopedics (Philadelphia): Hospitals and health systems can justify high upfront physician salaries because they capture downstream revenue across the continuum of care. This dynamic has accelerated consolidation, with the share of orthopedic surgeons in private practice now only about 50% (according to the AMA). At the same time, independent practices face mounting financial pressure: Medicare physician reimbursement has declined by nearly 30% in real terms over the past two decades, while practice costs have risen substantially.
Yet, independence is not obsolete; it is evolving. Solo practice is increasingly untenable, but physician-led groups can still achieve leverage through scale, shared infrastructure, and alignment. As reimbursement stagnates, physicians must pursue compliant ancillary revenue streams, particularly in surgical specialties, through ownership in ambulatory surgery centers, imaging centers, and physical therapy, among other service lines. Strategic joint ventures and MSO partnerships can offload administrative burden while preserving clinical autonomy.
In this evolving model independence persists, not in isolation, but through organized, capital-efficient physician enterprise.
Brandon Ortega, MD. Orthopaedic Spine Surgeon at Long Beach (Calif.) Lakewood Orthopaedic Institute: What we’re seeing is a divergence between physicians who have the subspecialty leverage, procedural volume or media presence to negotiate from strength, and those who do not. For orthopedic spine surgeons in particular, the demand for complex revision surgery, motion preservation, and medico-legal expertise creates a real runway for independence or hybrid models, whether through private group practice, ASC ownership or medical-legal work. The physicians who are losing ground are those in cognitive specialties or primary care who lack negotiating leverage in an increasingly consolidated system. So the independent model isn’t dying, but rather, it’s becoming a premium tier that is accessible to fewer and requires much more intentional business architecture to sustain.
Fred Watkins. Plastic Surgeon at Inova Fairfax Hospital (Rockville, Md.): Eliminate volume bonuses in urgent care settings.
Example: as former medical director for four high acuity immediate care clinics, a pattern was noticed among 27 physicians working at our clinics. Bonuses were paid for those seeing 35 patients in a 12 hour shift, & additional bonus paid when seeing 40 patients. Physicians seeing higher volumes to meet bonus criterias were noted to prescribe antibiotics and albuterol inhalers for almost all patients presenting with viral upper respiratory symptoms, and not providing any education on why antibiotics are not needed for the common cold. In fact, studies show that antibiotic resistance may be fueled by the prescribing practices of ER and urgent care doctors who prescribe antibiotics for the common cold at the following rates: ER 83 %, urgent care 61%, specialists 37%, primary care 17%. Our high volume physicians had more bounce back visits for patients that were not diagnosed or treated appropriately. Higher quality of care, less antibiotics for the common cold with patient education led to decreased repeat visits. However, physicians that provided appropriate care were less likely to receive volume bonuses. The lowest paid physicians are actually more likely to observe the recommended standards of care.
Furthermore, physicians who prescribe antibiotics for the common cold were found to be more likely to get higher patient satisfaction scores than those who recommended supportive care only but spent more time with the patient. Patients give higher satisfaction scores to doctors who are quick and give them what they expect, not what they need.
Aqib Zehri, MD. Neurosurgeon at The Oregon Clinic (Portland): I would say it is changing form overall. It is getting harder for doctors to stay fully independent because the business side of medicine is becoming more complicated. Labor costs are increasing, staffing is harder, payer rules are tougher and hospitals and health systems have more control than they used to.
That said, I do not think independent medicine is going away. I think it is shifting into a new model. In many cases, doctors are still practicing with some level of independence, but now they are doing it through partnerships with hospitals, larger groups, or other support structures.
The real issue is whether doctors still have meaningful control over clinical decisions, fair pay and a clear understanding of how the business works. So in my view, the independent physician model is not disappearing. It is just adapting to a more rapidly evolving healthcare environment.
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.