Alexander Vaccaro, MD, PhD, MBA, has been performing complex spine surgery for 33 years. Today, he can do some operations in nearly half the time they once took him.
That is what decades of experience are supposed to produce: A surgeon becomes faster while also lowering their complication rate. Anesthesia time falls. Blood loss can decline. Patients may recover sooner. The healthcare system spends less.
Under a new Medicare payment proposal, Dr. Vaccaro sees a troubling interpretation of that progress. The surgeon got more efficient. Therefore, the work must be worth less.
“To say that you’re going to pay less because you’re better doesn’t make any sense in the medical economic equation,” Dr. Vaccaro, president of Philadelphia-based Rothman Orthopaedics and U.S. president of the International Society for the Advancement of Spine Surgery, told Becker’s.
That argument is at the center of ISASS’ challenge to CMS’ proposed 2027 Medicare Physician Fee Schedule.
CMS issued the proposed rule July 14, 2026, with policies set to take effect Jan. 1, 2027, following a public comment period. The rule proposes a 1.19% decrease in the conversion factor for physicians participating in qualifying alternative payment models and a 1.68% decrease for those who are not. The decreases reflect several factors, including the expiration of a one-year 2.5% conversion-factor increase enacted for 2026.
The society has asked CMS to exempt three lumbar decompression and fusion codes, CPT 63030, +63052 and 22633, from a proposed efficiency adjustment. The group argues that shorter procedural time does not necessarily mean less physician work because technical skill, operative judgment, patient risk, and postoperative responsibility do not fall in proportion with minutes in the operating room.
But Dr. Vaccaro sees a much larger issue than three codes.
Medicare is trying to promote efficiency, move appropriate care into lower-cost settings, and make physicians more accountable for value. He supports all three goals. His concern is that the payment system is increasingly measuring the part of efficiency that is easiest to see, time and claims, while missing the physician judgment that made those efficiencies possible.
If that continues, he believes the eventual consequence will not simply be lower surgeon reimbursement. It will be fewer surgeons willing to take the most complicated Medicare patients.
The faster surgeon is not doing less work
Dr. Vaccaro offered a simple thought experiment.
Imagine an operation that takes the median surgeon two and a half hours. A surgeon who has performed the procedure for decades may be able to complete it safely in an hour and 20 minutes.
Should the second surgeon be paid less because the operation ended sooner? For Dr. Vaccaro, the answer exposes the problem with equating time and work.
A faster, safer operation may reflect experience, technical mastery, and better decision-making. It also means less anesthesia exposure, less blood loss, and a shorter recovery. Those are efficiencies healthcare policy generally wants.
Gains in efficiency normally lead to decreases in costs,” he stated. “Within an ordinary supply and demand paradigm, such a connection would be reasonable. However, it does not exist in surgical patient care.”
ISASS makes a similar distinction in its letter to CMS. Time and intensity, the society argues, are not interchangeable.
An advance that lets a surgeon finish an operation faster does not automatically reduce the concentration of judgment, technical execution or patient risk within those minutes. Nor does it remove the surgeon’s responsibility before the incision or after the wound is closed.
That becomes especially difficult to justify, Dr. Vaccaro said, when the expenses surrounding physician practice are moving in the opposite direction.
Everything around the operation is getting more expensive
The cost of performing a spine operation does not fall simply because the surgeon gets faster. Staff salaries, malpractice premiums, and technology costs continue to rise. Administrative requirements consume physician and staff time, while years of education and training delay surgeons’ entry into their peak earning years.
Dr. Vaccaro argues those costs have to be part of the equation if Medicare wants to understand the true cost of delivering care. His concern is that reimbursement policy instead relies too heavily on measures such as procedural time that do not capture all of the resources and expertise required to care for a patient.
“They’re not using the number one economic assessment tool that we have today, which is time-driven cost accounting,” he said.
Rothman has used versions of time-driven costing for years, he said, tracking the resources consumed across the care journey rather than simply looking at the final claim.
The equation itself is familiar: Value = outcomes divided by cost.
The problem, Dr. Vaccaro said, is that the current system doesn’t consistently measure either side with enough precision. Spine already has established patient-reported outcome measures capable of capturing pain, disability and functional improvement. ISASS has asked CMS to test a model linking those outcomes with time-driven measurements of what an episode of care actually consumes.
If CMS wants to reward value, Dr. Vaccaro argues, it should pay attention to whether the patient got better and what it truly cost to get them there. Not simply how long the surgeon’s hands were operating.
The efficiency paradox gets sharper in the ASC
The same problem follows spine surgery out of the hospital. CMS has increasingly encouraged appropriate procedures to migrate into ambulatory settings. Spine surgeons have helped make that possible through minimally invasive techniques, enhanced recovery, advances in anesthesia, and better patient selection.
A hospital stay can become an outpatient episode. The facility cost falls. The surgeon’s responsibility does not disappear with it. ISASS argues it may actually become more concentrated.
The physician still determines whether the patient belongs in an ASC at all. The surgeon remains responsible for optimization, operative planning, complications, neurologic assessment, and postoperative surveillance.
That patient-selection decision becomes particularly important as more complicated surgery migrates outward. The surgeon has to recognize not only who can safely go home, but who cannot.
For Dr. Vaccaro, that is another example of policy potentially confusing a cheaper setting with less professional responsibility. The facility became more efficient. The physician did not become less accountable.
He supports accountability — if surgeons are accountable for what they control
Dr. Vaccaro does not reject value-based care. He wants more of it. He supports measuring infection, readmission, reoperation, and functional outcomes. If one surgeon consistently produces worse risk-adjusted results, he sees nothing unreasonable about a payment model recognizing that.
“If CMS comes in and says, ‘We’re focusing on value’” and ties payment to meaningful outcomes, “it makes sense to everybody,” he said. “I don’t think anyone will argue with that at all.”
The harder question is attribution. A spine surgeon may enter a patient’s care after months of physical therapy, imaging, injections, medications and other nonsurgical treatment.
If Medicare assigns financial responsibility for the entire low-back-pain episode to the surgeon who appears near the end, Dr. Vaccaro argues it can hold that physician accountable for costs they did not order and could not control.
ISASS raised the same concern around the Ambulatory Specialty Model. The organization told CMS that financial accountability should follow “actual clinical responsibility and the ability to influence care” rather than simply the point at which a surgeon enters the episode.
That does not mean spine surgery has no unnecessary variation. Dr. Vaccaro acknowledges it does. The better policy question, he argues, is how to distinguish unwarranted variation from differences driven by anatomy, deformity, previous surgery, neurologic risk and medical complexity. That requires clinical data. A broad efficiency assumption cannot make the distinction.
The individual cuts hide the larger squeeze
One of ISASS’ most consequential requests has almost nothing to do with a particular procedure. The society wants CMS to show the cumulative effect of its policies on individual specialties.
A conversion-factor change may appear small. So can a work relative value unit revision. A practice-expense change. A site-of-service adjustment. A global-surgery policy. An efficiency adjustment.
Taken one at a time, each may look manageable. Stacked over years, ISASS argues they can produce something different: progressive compression of the resources available to physician practices.
The society has asked CMS to publish specialty-specific analyses showing that combined effect rather than forcing physicians to reconstruct it provision by provision.
Dr. Vaccaro calls the current process too opaque.
“We get rid of all the black boxes and how they determine who gets paid and not get paid,” he said. That matters because the consequences of physician payment policy are not confined to physician income. At some point, practices respond.
The first thing to break may be access
Dr. Vaccaro believes private practice is particularly exposed. A large health system can negotiate across thousands of clinicians, facilities, and service lines.
An independent practice has fewer places to absorb persistent losses. If Medicare payments keep falling while the cost of delivering care rises, physicians eventually face decisions that have little to do with clinical preference.
They can consolidate. They can go out of network. They can limit Medicare. Or they can stop taking it.
“If you keep on paying less and less and less, patients will have less access,” Dr. Vaccaro said.
He worries the pressure is especially acute for complicated cases, where surgeons assume greater technical risk and malpractice exposure as the economics become less attractive.
In that environment, he argues, surgeons may become less willing to take the most difficult cases, transferring patients elsewhere, delaying surgery or declining cases altogether. Dr. Vaccaro believes that can ultimately increase Medicare spending rather than reduce it and produce a healthcare system he finds even more troubling.
‘We cannot let America go in that direction’
Dr. Vaccaro has seen versions of the endpoint overseas. A public system provides one level of access. Patients who can afford it purchase another. He worries persistent reimbursement compression could push American specialty care toward the same two-tier structure.
The signs, he said, already exist. Patients with money and connections can often find a way to get care when access becomes scarce. Others wait.
“That’s horrible,” he said. “You have to democratize medical care.”
That is the patient-access argument underneath ISASS’ technical comments to CMS. The fight over an efficiency adjustment can look like a fight over reimbursement methodology. Dr. Vaccaro believes it is really a question of what behavior Medicare wants to incentivize.
If a surgeon becomes faster, safer and capable of moving appropriate care into a cheaper setting, should the payment system treat those achievements as evidence that the physician contributed less? Or should it ask whether the patient received a better outcome at a lower total cost?
ISASS put the distinction plainly in its letter: “Healthcare payment should not reward only efficiency. It should reward value.”
For Dr. Vaccaro, the danger is not that Medicare wants spine surgery to become more efficient. It already has. The danger is creating a system in which the physicians who made it more efficient see that success translated into lower valuation of their work.
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.
