Reimbursement is tightening, operating costs are climbing and competition from hospitals and national platforms is accelerating. Yet a growing number of orthopedic and spine surgeons are responding not by retrenching but by redesigning their business models and restructuring partnerships to protect autonomy, widen access to capital and grow compensation.
During a featured session at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in Chicago on June 12, four industry leaders examined how those models are taking shape. The participants were:
- Paul Eichenseer, DO, chief physician officer at OrthoAlliance
- Dana Jacoby, president and CEO of Vector Medical Group
- Wael Barsoum, MD, President and Chief Transformation Officer of Healthcare Outcomes Performance Company
- Gary Herschman, shareholder and co-chair of the Healthcare Transactions Group at Baker Donelson, who moderated
Below are five takeaways from their conversation.
Note: Quotes have been edited for length and clarity.
1. Consolidation is back, and the second wave looks different
Dealmaking in the musculoskeletal space was relatively quiet in 2025 but has surged in 2026, Ms. Jacoby said, driven heavily by reimbursement cuts that pushed more orthopedic care into outpatient settings. The first wave of orthopedic roll-ups crested in 2021 and 2022, she noted.
“Those are now coming to maturation. And so a lot of them are on the runway for second bites,” said Ms. Jacoby, who noted that six large orthopedic groups are back on the market and that pain practices are consolidating at an especially fast pace.
2. Strategic joint ventures are reshaping the field
Mr. Herschman pointed to a string of novel, multi-party structures — including a multiparty joint venture involving Hospital for Special Surgery, its orthopedic surgeons, private equity firm General Atlantic, and Legent Health (a growing ASC company) — designed not just to run existing surgery centers but to expand nationally under a recognized clinical brand.
Dr. Barsoum said that brand strength is the underappreciated asset in such deals, because it lets a network move “upstream” of payer steerage and shape where patients ultimately go to seek out care. Geography, he added, is decisive: selective operators walk away from markets with weak reimbursement and poor health-system quality scores, however strong the local surgeons may be.
3. Real physician governance is the make-or-break variable
Dr. Eichenseer described OrthoAlliance’s overhaul of its partnership model, built on physician governance over finance, operations, growth and clinical quality. The model also includes a compensation formula in which savings on direct expenses flow directly to the physician’s own bottom line rather than into a shared pool. He underscored the distinction between genuine and cosmetic governance.
“Real governance is the absolute key to this. If it is governance in name only … they’ll continue to disengage,” Dr. Eichenseer said, warning that non-competes and the promise of a future liquidity event lose their hold once they expire.
4. Private equity works best as capital, not as operator
The platforms that struggle, the panel agreed, are those where investors try to run the business; the ones that thrive treat private equity as a funding source and a financial brain trust while leaving operations to physicians. Dr. Barsoum likened HOPCo’s approach to financing any other investment — a loan against an asset — and stressed up-front transparency about the economics, including the standard private equity “scrape,” which is the recurring management fee the platform takes off the top. The platform never dictates clinical policy or volume, he said.
“We have never gone to one of our platform practices and said, hey, we need you to … add 12 more patients to every doctor’s schedule,” Dr. Barsoum said, describing HOPCo’s role instead as handing physicians the financial roadmap and letting them decide how to follow it.
5. New revenue streams are the path beyond the scrape
With most musculoskeletal surgeries now able to be performed in an ASC, the panel argued that durable practices will diversify income beyond traditional payer bundles. Ms. Jacoby pointed to direct-to-employer contracting, capitated arrangements and bundled-payment initiatives as long-discussed concepts now made viable by AI and stronger actuarial data. Dr. Barsoum stressed that clinically integrated networks, risk-bearing arrangements and partnerships with health systems improve quality and lower cost per case, noting that such work requires real claims-analytics infrastructure most small practices cannot build alone.
Where surgeons go from here
The through-line across the panel was control: surgeons who structure partnerships around genuine governance, the right kind of capital and diversified revenue are positioning themselves to grow compensation and protect autonomy, while those who cede operations or chase serial liquidity events risk disengagement and stagnation. As reimbursement pressure intensifies and bundled and direct-to-employer models gain traction in the coming years, the surgeons who treat structure as a strategic lever — not a one-time transaction — will be best positioned to capture the upside.
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.