Deeptee Jain, MD, knows what every payer she works with pays her for every procedure she performs. She wishes she didn’t have to.
Dr. Jain trained to become a spine surgeon, not to study payer contracts, collections or practice overhead. But after moving from academic medicine into private practice, she came to a realization that changed how she thinks about the job.
A surgeon can be extremely busy and still be part of a financially unhealthy practice.
“A busy practice is not necessarily a profitable practice,” Dr. Jain told Becker’s.
For physicians whose economics depend heavily on professional collections, she believes understanding the business of care can no longer be someone else’s responsibility. Surgeons need to know what they are paid, what it costs to deliver care and where money quietly disappears.
Her larger argument, however, is not that surgeons need to become accountants. It is that a spine practice built principally around performing procedures is becoming harder to sustain. The stronger model, she believes, takes responsibility for more of the patient’s care before and after an operation.
When volume hides the problem
Dr. Jain, a minimally invasive spine surgeon at the Royal Palm Beach, Fla.-based Center for Bone and Joint Surgery of the Palm Beaches, came to understand that reality after leaving academic medicine for private practice.
“I thought these things weren’t important because I lived in this ivory tower,” she said. “But that is just absolutely not the case.”
Today, she closely watches collections, denials, authorization times, staffing costs and uncompensated administrative work.
She also cautions against optimizing a metric without understanding what it actually measures. Consider clinic utilization. Dr. Jain deliberately maintains enough appointment capacity that patients can get into her clinic quickly, even if that produces a lower utilization rate than a completely booked schedule.
“I’d rather have 60% utilization and allow a patient to call and make an appointment the next day than have 100% utilization and potentially lose that patient,” she said.
The principle extends beyond scheduling. “Metrics can be super misleading if you don’t understand them on a detailed basis,” she said.
For Dr. Jain, operational discipline means understanding the numbers without allowing a single metric to define a successful practice.
The uncomfortable economics of surgery
Asked where spine practices may be losing money without realizing it, Dr. Jain pointed to the service she spent years training to provide: surgery.
“The one that no one wants to talk about is surgery,” she said.
Her concern is particularly acute for insurance-based practices whose reimbursement is tied directly or indirectly to Medicare. As overhead rises and professional reimbursement remains under pressure, she believes some procedures no longer generate enough professional revenue to justify the resources required to provide them.
Eventually, she said, some physicians stop accepting certain insurance. That is where a practice’s financial problem can become a patient’s access problem.
Dr. Jain has watched that dynamic play out in South Florida, where a surgeon known for an approach widely used for anterior lumbar interbody fusions recently stopped accepting Medicare. Although Dr. Jain still accepts Medicare, she said the change has made it more difficult for those patients to access ALIF when she believes it is the appropriate surgical option.
“You can drop prices all you want, but then what happens?” she said. “That means that the surgeons no longer accept Medicare.”
For Dr. Jain, that is the larger consequence of reimbursement pressure. The immediate effect appears on a practice’s balance sheet. The downstream effect can emerge when a patient tries to find someone willing and able to provide the care.
From procedure to continuum
For Dr. Jain, the answer is to look beyond the operation. Physical therapy, imaging, durable medical equipment, medication management, in-office procedures and ASCs can create value beyond professional surgical fees.
“They allow patients to get centralized care and easy access to care in a world that’s super, super fragmented,” she said.
Her thinking on this point has evolved. Earlier in her career, Dr. Jain believed surgeons should principally do what they had spent years training to do. Her partners in private practice taught her to think more broadly.
“They taught me the value we can bring to patients when we care for them from start to finish,” she said.
That does not mean every patient should become a surgical patient.
Some practices measure surgical conversion rates, or the share of new patients who ultimately undergo an operation. Dr. Jain thinks that creates the wrong incentive.
“I think that’s wrong,” she said. “And I actually don’t think it’s financially smart.”
A patient may need therapy, medication management or another nonsurgical intervention. Taking responsibility for that patient rather than viewing the encounter through its likelihood of producing an operation, she argues, can align patient care with a more durable practice model.
“We want to take care of their problem, the whole patient, and that doesn’t mean that we have to operate on them,” she said.
That leads to what Dr. Jain sees as the larger opportunity for spine practices. “Managing the entire spine care continuum is going to create the greatest value for the practice and the greatest benefit for patient care,” she said.
That strategy also requires deciding how to participate in ambulatory care, she said, whether through owning, partnering with or simply using ASCs and other outpatient services.
The AI-native spine practice
Dr. Jain sees another opportunity in the work surrounding patient care that does not require a surgeon and, increasingly, may not require a person.
Her interest in AI is practical. She is less focused on replacing clinical judgment than on check-in, referrals, billing, revenue cycle management and other repetitive administrative tasks.
“We want to use technology to reduce administrative friction and improve access,” she said.
In her own practice, certain health maintenance organization referrals require staff to manually check a chart, search a separate portal and, in some cases, contact the referring physician’s office.
“That is a task that could totally be automated,” she said.
With staffing among a practice’s largest expenses, Dr. Jain believes those efficiencies will become increasingly important. She also pushes back on describing AI as a distant transformation.
“It’s not the future,” she said. “It’s present day.”
Her advice to a surgeon starting a practice now is correspondingly direct: Build it AI-native. An established practice has to rework existing processes. A new one can decide from the beginning which tasks actually require human attention.
What surgeons were never trained to learn
Technology does not eliminate the need for financial vigilance.
Dr. Jain learned that firsthand after discovering that one payer was reimbursing her practice for a particular procedure at roughly 10% of the Medicare rate, she said. The discrepancy had not been flagged by the practice’s existing system.
She found it manually months later. The payment, she said, did not cover the practice’s basic costs associated with providing the service.
“You have to pay attention to every single line item,” she said.
That can sound like an argument about money. Dr. Jain sees it as an argument about whether a practice can continue providing care. If delivering a service consistently costs more than a practice receives for it, eventually something has to change. A practice may absorb the loss, renegotiate the arrangement, stop providing the service under that contract or direct the patient elsewhere.
Ignoring the economics does not make them disappear. It can allow financial pressures to shape what care a practice can continue providing before the surgeon fully recognizes the problem.
Dr. Jain still considers herself a surgeon first. “I do spine surgery when it’s the right thing for the patient,” she said.
But she no longer believes a strong spine practice can be built around the operating room alone. The practice she envisions understands where it makes and loses money, automates administrative work that adds little value and takes responsibility for the patient’s care whether or not that care ends in an operation.
Medical training taught Dr. Jain how to operate. Private practice taught her that sustaining a spine practice requires understanding everything around the operation, too.
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.
