Private Practice Neurosurgery vs. Hospital Employment

​​Private practice neurosurgery has become one of the strongest drivers of income variation within the specialty, especially as compensation models continue to evolve.

Neurosurgeons are by no means typical physicians. On the pay scale, they are at the very top. But the numbers get a lot more granular when you consider where a surgeon works and what type of compensation structure they are under. A neurosurgeon salary can differ by hundreds of thousands of dollars depending on whether the surgeon works in a private practice or a hospital-employed position.

For physicians at the point of negotiating their first or future contracts, understanding what drives differences in neurosurgeon salary can lead to better long-term compensation.

National Average Neurosurgeon Salary

According to the 2024 Physician Compensation Report by Physicians Thrive, the average neurosurgeon salary ranks highest among all medical specialties, with a median annual income of $788,000.This number is the sum of a base salary, productivity incentives, and bonuses and includes boh private practice neurosurgery as well as hospital employment.

Regional variation plays a key factor in compensation. The same report noted that median neurosurgeon pay was nearly $959,000 in the West, about $900,000 in the Midwest, $812,000 in the South, and approximately $731,000 in the East. The cause of these large gaps stems from supply and demand and includes local provider shortages, regional payer mixes, and different reimbursement rates from commercial, Medicaid, and Medicare patients.

Outside of the U.S., neurosurgery is not as financially lucrative. For example, the average neurosurgeon in Canada can expect to make the equivalent of $350,000–$400,000 USD per year. The U.S. will continue to be the top choice for compensation.

Private Practice Neurosurgery: Highest Average Salary

A physician-owned or independent practice can often bring in the highest average neurosurgeon salary. This is typically true of any specialty. A report by NERVES, a neurosurgery practice management service, found that neurosurgeons in physician-owned practices earned a median of $862,938 in 2023. Neurosurgeons employed by a hospital earned a median of $766,648. These dynamics help explain why private practice neurosurgery remains one of the most competitive and financially rewarding paths in the field.

Income drivers in private practice include:

• Productivity-Based Models: As noted, compensation is usually tied to RVUs or net collections. This drives high surgical volume.
• Ownership Equity: In multi-owner practices, partners are entitled to a share of the profits on imaging centers, ASCs, and any other revenue-generating components of the practice.
• Negotiation Flexibility: Independent groups are free to negotiate directly with payers, hospitals, and ancillary providers, customizing contract terms to drive volume.

These advantages do come at a cost, however. Private practice neurosurgery comes with responsiblity for overhead expenses, staff management, and the highest malpractice insurance premiums in medicine. Shifts in the payer mix or economic downturns can result in income volatility.

Another advantage is the level of autonomy private practice neurosurgeons enjoy. Physicians can shape their clinic structures, select ancillary services, define scheduling preferences, and build referral networks strategically. This level of control often translates into both higher earning potential and greater professional satisfaction for surgeons who prefer an entrepreneurial path.

At the same time, financial success in private practice neurosurgery often depends on strong business acumen. Physicians must make informed decisions about payer contracting, capital investments, staffing levels, and marketing. Those who manage these components effectively can outperform their hospital-employed peers by a substantial margin.

Hospital Employment: Stability and Benefits

In contrast, hospital-employed neurosurgeons typically earn a lower neurosurgeon salary but benefit from predictable paychecks and comprehensive benefits. Hospital contracts provide malpractice insurance and tail coverage, robust retirement and health benefits, and typically include guaranteed salaries and paid time off. This tradeoff is a major consideration for surgeons deciding between hospital roles and private practice neurosurgery, especially early in their careers.

Scheduling predictability is another advantage. Many hospital-employed neurosurgeons work within shift-based models or predefined call rotations, which can reduce variability in weekly hours. This consistency can be especially beneficial for surgeons balancing family responsibilities or seeking more structured workweeks.

Hospital roles also tend to offer clearer promotion pathways, with opportunities for leadership positions such as service line director, department chair, or medical director. While these roles may not match private practice neurosurgery earnings, they often come with administrative stipends and reduced clinical expectations, creating a more balanced long-term career trajectory.

Other advantages include:

• ​Employer-paid malpractice insurance and tail coverage
• Robust retirement plans, health benefits, and paid leave
• Access to cutting-edge equipment, research opportunities, and teaching appointments

Hospital-based contracts are appealing for their security, but caps in compensation structure can be long-term detriments for income growth. Bonuses based on RVUs, collections, and quality metrics are unlikely to match the upside potential of private practice neurosurgery.

Regional Differences and Demand

As with the general workforce, geography affects both private practice neurosurgery and hospital salaries. Western states including California, Nevada, Oregon, and Washington boast the highest median income, which was nearly $959,000. Southern states were the lowest in average compensation, with an average income of $655,220, which is partly due to payer mix and lower reimbursement.

The state-by-state data from the Medical Group Management Association (MGMA) show that the state-level median salary can often be much higher than the national average, especially in the Southeast. South Carolina’s median neurosurgeon compensation, for example, was over $1.4 million in 2025.

Neurosurgeons and other physicians with in-demand sub-specialties can also demand premium salaries and signing bonuses by working in shortage areas.

Incentives and Bonuses

Incentives also shape day-to-day decision-making. Productivity bonuses may encourage surgeons to increase case throughput or expand clinic hours, whereas quality-based incentives often reward careful documentation, lower complication rates, and multidisciplinary collaboration. Understanding how these incentives influence workflow can help both those in private practice neurosurgery and hospital employment to select contracts aligned with their preferred practice style.

Across all specialties, 59% of physicians reported receiving an RVU-based bonus in 2023, with neurosurgeons having a high incidence. Signing bonuses for physicians in 2023 averaged $37,473, which was a 20% increase from the previous year, and are typical for physicians relocating for new roles. Relocation expenses are also a common bonus.

Outside of productivity bonuses and incentives, private practice neurosurgery may offer year-end profit sharing. Hospital-employed neurosurgeons and other physicians tend to receive bonuses tied to performance or quality metrics.

It’s also worth noting that incentive terms are one of the most negotiable parts of a neurosurgeon’s contract. Surgeons with subspecialty training or strong referral patterns can often secure more favorable RVU thresholds, higher bonus caps, or even guaranteed minimums in their first year, all terms that can significantly alter total compensation over time.

Workload and Lifestyle Considerations

No conversation about compensation can be complete without considering workload. Neurosurgery is among the most time-intensive specialties, requiring extended clinical hours, frequent call coverage, and substantial administrative workload beyond direct patient care. This workload contributes to burnout, which remains one of the highest in medicine.

Hospital-employed physicians may have more consistent schedules and administrative support, while those in private practice neurosurgery may allow for more flexibility at the cost of higher managerial responsibility. Hospital-employed surgeons typically rely on dedicated staff for billing, coding, and pre-authorization work, whereas private practice neurosurgeons often manage or oversee these functions themselves. The additional business responsibilities can expand total weekly workload even when clinical hours remain steady.

Call expectations also differ meaningfully between the two settings. Hospital-employed neurosurgeons often rotate within larger teams, reducing the frequency of overnight call, while private practice group, especially smaller ones, may shoulder heavier call schedules tied to their partner hospitals. These distinctions can influence both day-to-day satisfaction and long-term sustainability in each career path.

Make the Most of the Neurosurgeon Salary

Whether to choose private practice or hospital employment is a decision that can only be made after serious consideration of personal goals and priorities. For surgeons drawn to autonomy, business growth, and procedural volume, private practice neurosurgery often offers the greatest long-term financial upside. while neurosurgeons who want a more predictable salary with teaching and research opportunities will lean towards hospital employment.

Both pathways can lead to the highest salaries in medicine. With neurosurgeon salary already at the top and demand projected to increase, proper planning and decision-making now can turn today’s compensation into long-term wealth.

At Physicians Thrive, we empower neurosurgeons and other physicians to maximize their earning potential, whether through contract review, insurance planning, or long-term wealth management. Contact us today to find out how we can best help you in your unique situation.

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