Spine surgery is increasingly defined by a tension few outside the field fully see: the collision of clinical complexity and economic constraint. For surgeons like Oliver Tannous, MD, an orthopedic spine surgeon at Washington, D.C.-based MedStar Washington Hospital Center, that tension isn’t abstract, it is shaping, in real time, which patients get treated, where and how.
At tertiary care centers, the system still absorbs the most difficult cases. But beyond those walls, the ground is shifting.
“The huge advantage that I have is I’m hospital employed, and specifically, I work at a tertiary care center,” Dr. Tannous said. “The mission of the hospital is to be the final stop for all care, and so it has enabled me to continue with complex surgeries.”
That protection, however, is uneven, and increasingly fragile.
A quiet sorting of patients
In community settings, the calculus is different. Hospitals that are not built for high-acuity care are making practical decisions about what they can safely support, and surgeons are adjusting accordingly. “There is a lot of pressure to avoid some of those more complex cases,” Dr. Tannous said. “The hospital is not set up for complex patients, whether it’s anesthesia care, ICU care or ancillary care.”
Even when surgeons have the technical ability, infrastructure gaps push complex patients toward tertiary centers. At the same time, financial incentives are pulling surgeons toward lower-risk procedures.
As reimbursement declines, more spine surgeries are moving into ASCs, where the economics are more favorable.
“Surgeons will say, ‘Maybe I’m better off doing more bread-and-butter cases in the ASC,’” he said. “The ASC benefits from facility fees, and many surgeons now have equity stakes that allow them to benefit passively.”
The result is a quiet but consequential sorting system: Simpler cases shift to outpatient, while the most medically complex patients are concentrated in hospitals designed to absorb risk.
When value ignores variation
That divide becomes sharper under value-based care models, which often flatten meaningful differences among cases.
“I don’t think they account for complexity,” Dr. Tannous said. “A lumbar fusion is a lumbar fusion, so all lumbar fusions are going to fall under the same value-based care.”
But in practice, those cases are not interchangeable.
“There’s a big difference between a one-level fusion in a younger, healthier patient who goes home the next day, versus a seven-level fusion in a 75-year-old with comorbidities who stays in the hospital for a week and may have a complication,” he said.
For now, hospitals are relying on margins from lower-acuity procedures to offset losses from more complex ones, a strategy that may not hold.
Slowing the decision
In a system that rewards volume, Dr. Tannous has built a practice that deliberately slows down surgical decision-making, particularly for complex cases. “I almost never make that decision during the first clinic visit,” he said. “Sometimes it takes two or three visits.”
The approach reflects how patients process high-stakes information. Initial consultations are often overwhelming, limiting how much patients can absorb. “The first visit is information overload,” he said. “The patient is anxious and they’re going to miss most of what I’m saying.”
Subsequent visits, often with family members present, allow patients to better understand both the risks and the reality of surgery. Over time, patients begin to self-select. “When you really understand what it’s like to go through a complex procedure and what the risks and benefits are, those who are ready will move forward,” he said. “Those who are not ready will make the decision not to do the surgery.”
It is a slower model, but one he believes leads to better outcomes, clinically and emotionally. “The last thing I want is a devastating complication,” he said. “It ruins the patient’s life, and it ruins my life as well. You’re very much emotionally invested as well as physically invested as a surgeon.”
What “failure” really means
At tertiary centers, surgeons frequently see patients after prior spine surgeries that did not achieve the intended result. But Dr. Tannous is careful not to reduce those cases to simple explanations. “You can’t say it failed because other surgeons aren’t as good,” he said. “I don’t think that’s a fair answer.”
Instead, he points to the complexity of patient physiology and healing.
A patient may have diabetes, renal failure or other systemic conditions that impair recovery. In other cases, the surgical construct may not have been sufficient, even if the initial decision-making was sound.
“In the moment, that surgeon made the right decision,” he said. “There was no malpractice. It just wasn’t enough.”
Revision surgery, he said, requires a far more aggressive and comprehensive approach. “You go back to the toolbox and throw the kitchen sink,” he said. “You really only get one shot to fix a failed surgery.”
The slow financial squeeze
Underlying these shifts is a broader financial trajectory that, in Dr. Tannous’ view, is unavoidable.
“There’s no way CMS is not going to keep cutting,” he said. “They’re going to keep trying to find places to cut.”
The effect is incremental but compounding: reimbursement declines while inflation rises. “You have inflation going up and reimbursement coming down,” he said. “Now you’re getting a three to 5% delta every year.”
Hospitals respond not with sweeping changes, but with a series of small constraints that accumulate over time.
“You can’t use this screw system or this bone graft because it’s too expensive,” he said. “Any one change on its own is relatively benign, but when you add multiple changes, they start to compound.”
Over time, he warned, those compounding decisions may begin to affect care. “We’re not there yet, but we’re very much moving in that direction,” he said.
A widening divide
Perhaps the most consequential shift is not clinical, but structural: a growing divide in what patients can access based on their financial resources.
“The U.S. is starting to diverge,” Dr. Tannous said. “You’re going to have those who have and those who don’t.”
Some patients are already navigating around coverage limitations to access newer technologies. “I see patients who would benefit from a lumbar disc replacement, but insurance will pay for a fusion and not the disc replacement,” he said.
Those with resources pursue alternatives. “They’ll go out of network or even go to Germany to get the disc replacement,” he said.
Others are left with what is covered, even when it may not be the best option.
“What is currently deemed the standard of care isn’t necessarily the best option out there,” he said.
In spine surgery, the gap is no longer just clinical. It is becoming economic, and increasingly, unavoidable.
