Why I Closed My Surgical First Assisting Business

The New York Times says surgical assistants are gaming arbitration. They're right. But I lived the broken math underneath it, and that story matters more.

The New York Times recently reported that some surgical assistants are using a loophole in the No Surprises Act to win enormous arbitration awards, in some cases earning many times more than the surgeon.

The numbers in that story are real, and they are indefensible.

But I read it with a perspective most readers don't have. I owned a surgical first assisting company. And I chose to shut it down.

Why I started a first assisting business

After 5 years as a PA in cardiothoracic surgery, I knew exactly what a skilled first assist is worth in the operating room. What I did not know was how much revenue I was capable of producing.

I was full service, meaning my duties followed patients through their entire surgical journey, from consult to discharge, alongside the surgeons and often more than the surgeons themselves, since we rounded more often and took care of all patient communication.

I loved it. But the schedule was brutal, I was on call a lot, I had no life, and hospitals were squeezing their employees hard after the 2008 economic crash. For context I graduated in 2007.

I felt the tension between wanting to be at the top of my career, wanting a life, being burned out, and the tick tock of my peak fertility years whizzing by.

I was desperate for flexibility and desperate to also stay in the OR because it was what I loved most.

So I left my hospital job and started a business as an independent contractor first assist.

At the time there were only about 28 first assistants in the country trained to do robotic intrathoracic surgeries, and I was one of them. The demand found me before I even went looking for it.

I built hospital contracts and per diem relationships with surgeons across several specialties, and eventually I was earning more than I ever imagined making as a PA. The business grew to the point that I hired an office manager, brought on a medical billing company to bill hospitals for my services, and contracted other first assists to handle case overflow.

On paper, I had won. Time freedom, income I could never touch as an employee, and work I genuinely loved.

But here is the truth about the surgical assisting business: I had traded one boss for five. Insurance companies, hospital administrators, contract lawyers, compliance, and restrictive PA laws all set the rules, and I still had to play by them.

Navigating that was challenging, but it was worth it to me as long as three things held true:

1. Above all else, we did right by the patients.

2. The profit margins sustained us.

3. I paid people fairly.

Those were the 3 rules I ran my business by. And I could not find a way to scale the business without compromising them in some way.

The balance billing problem

Doing right by patients mattered most to me, and that put me at odds with a very common practice among independent first assists: balance billing.

Balance billing happens when an out-of-network provider bills the patient directly for the gap between what the provider charged and what insurance agreed to pay. If a provider charges $1,000, insurance allows $700, and the patient has already paid their share of that $700, a balance bill is the provider coming after the patient for the remaining $300.

Surgical first assistants could do this legally at the time, and they did it a whole lot.

Surprise billing patients always felt nefarious to me. Open heart patients are frequently retirees on fixed incomes. Sending them a bill they never saw coming seemed wrong to me, even though it was legal.

So my business subsisted on what we could collect from the patient's insurance, and we never balance billed.

Why it didn't work at scale

Insurance companies did what they always do: fight to pay you anything at all. Unless I was working a locums deal, insurance reimbursement was my primary source of income. Without balance billing, and without paying my team less, the model became unsustainable.

My stress climbed. My frustration climbed. The trapped feeling I thought I had escaped came back wearing a different costume.

Then the pandemic hit, and the stress I had been outrunning finally caught me.

I kept working past my ability to compensate for the toll it was taking, because I did not want to burden my team. When rest and self-care stopped working, my body made the decision my head refused to make. I stopped completely.

That business was my baby, and I had to bury it. It was difficult.

Although it felt like it at first, closing the business was not a failure, because I never compromised my values. It was the tuition I paid to learn that revenue without leverage is just a better-paying trap.

I had no leverage against behemoth insurance companies. Nobody does. And that's what's most broken with healthcare.

Just as physicians in private practice became casualties of reimbursement cuts and ever-growing insurance red tape designed to delay care and avoid paying, so did I.

A year or so later, the No Surprises Act passed. I felt validated, both in my decision to walk away and in my refusal to balance bill.

The math of surgical first assist reimbursement

Here is what I learned running that company, and what the outrage over the NYT story skips.

The standard reimbursement for a surgical first assist is 16 percent of the surgeon's fee. Not 16 percent of the bill. Sixteen percent of what the surgeon is paid, a number insurers have spent two decades pushing down.

Then there is the network problem. Many insurers simply refuse to contract with surgical assistants at all. You cannot "just go in-network" when the network will not have you. In the Times' own reporting, one assisting company described being offered thirty dollars for a three hour robotic case.

That checks out to me completely. I got paid zero for many complex, long cases I assisted on, for the silliest of reasons, and had to contest them over and over and over again. It was as frustrating and draining as they designed it to be on all patient facing healthcare professionals.

They bet on nobody having the energy to keep fighting them.

Endoscopic vein harvesting pays $12 for assistants and its a skill that even surgeons don't know how to do. (most).

So picture the honest operator's position. The front door pays almost nothing. The insurers will not let you in. And a legal side door, arbitration, pays extravagantly.

Is anyone surprised that an industry grew up around the side door?

I'm not.

Why I walked away

I looked at my own numbers and faced a conclusion I did not like: there was no version of this business that was both honest and sustainable. I was not willing to build a company whose revenue model depended on staying out of network and betting on arbitration. So I closed it.

That decision cost me the non-traditional career path I built with my bare hands.

It also taught me more about surgical billing, payer behavior, and vendor oversight than any credential could have.

This is two problems, not one

Congress will almost certainly close the arbitration loophole. The pressure after this reporting guarantees it.

But nobody is working on the second problem: a reimbursement structure that made honest assisting nearly impossible to sustain in the first place. Close the side door without fixing the front door, and the coverage problem does not go away. It just gets quieter.

What this means, depending on who you are

If you run a hospital or surgical service line: you should be able to answer, today, how your assist coverage is structured, who bills for it, what their network status is, and how much of it touches arbitration. If you cannot, that is no longer just an efficiency question. Regulators and reporters are now looking. This review is the consulting work I do, and my inbox is open.

If you are a PA: this story is the loudest possible reminder of the thing I teach every week. The system does not automatically value your work correctly, in either direction. Know what your work generates. It is the foundation of every negotiation you will ever have.