Further payment cuts are the factor most likely to make spine surgeons reconsider Medicare participation, according to a recent Becker’s LinkedIn poll.
Among 112 respondents, 53% selected further payment cuts. Prior authorization ranked second at 18%, followed by administrative burden at 17%. Another 13% said nothing would cause them to stop accepting Medicare.
The results come as spine surgeons face another proposed Medicare payment reduction in 2027, new individual physician risk and an expansion of prior authorization into traditional Medicare.
Payment cuts are the clearest line
More than half of respondents selected further reimbursement cuts, far ahead of any other factor. CMS’ proposed 2027 Medicare Physician Fee Schedule would lower the conversion factor 1.68% for clinicians outside qualifying alternative payment models, from $33.40 to $32.84, and 1.19% for qualifying APM participants, to $33.17. CMS also estimates proposed relative value unit changes would reduce orthopedic surgery payments another 7% on average, excluding the conversion-factor change.
Alexander Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics and U.S. president of the International Society for the Advancement of Spine Surgery, recently told Becker’s that continued reimbursement compression could eventually affect which patients surgeons are willing to treat. “If you keep on paying less and less and less, patients will have less access,” Dr. Vaccaro said.
For some surgeons, that threshold has already been crossed. Brian Gantwerker, MD, president of The Craniospinal Center of Los Angeles, previously told Becker’s that the economics of Medicare participation became untenable in his practice. “The tipping point came when each Medicare patient became a net-net loss on each and every office visit,” Dr. Gantwerker said.
Ara Deukmedjian, MD, opted out of Medicare more than a decade ago after watching reimbursement decline. “The risk of being a Medicare in-network neurosurgeon provider far outweighed the benefits,” he told Becker’s.
Prior authorization is a close second to administrative burden
Prior authorization accounted for 18% of responses, narrowly ahead of broader administrative burden at 17%. The two pressures increasingly overlap.
CMS’ Wasteful and Inappropriate Service Reduction model brought prior authorization or pre-payment medical review into traditional Medicare this year for 17 services in six states. The list includes cervical spinal fusion, epidural steroid injections, percutaneous vertebral augmentation and image-guided lumbar decompression.
Grant Booher, MD, a neurosurgeon in Fort Worth, Texas, warned that the program could “delay care, increase administrative burdens and worsen outcomes.” Spine surgeons have also told Becker’s that prior authorization can require payer-specific documentation language, proof of conservative care, level-by-level coding and repeated appeals or peer-to-peer reviews.
Bryce Basques, MD, director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., described how those requirements are changing clinical documentation itself. “Writing notes no longer means documenting medical decision-making, but rather satisfying algorithms with appropriate buzzwords and phrases in order to get appropriate care for the patient,” Dr. Basques told Becker’s.
Dr. Gantwerker has described insurers requesting level-by-level CPT information, surgical systems and documentation of six months of nonsurgical care. Issada Thongtrangan, MD, an endoscopic and minimally invasive spine surgeon at MicroSpine in Scottsdale, Ariz., has described requirements involving physical therapy dates, medications, injections, patient-reported outcomes, disability scores and imaging.
The administrative cost goes beyond denials
The 17% of respondents who selected administrative burden point to a broader cost that does not appear in the payment attached to an office visit or surgery. Practices must staff authorization, billing, appeals, quality reporting and other compliance functions even as reimbursement falls. Physicians spend an estimated 53 hours annually on tasks associated with the Merit-based Incentive Payment System, costing about $12,800 per physician.
Paul Vessa, MD, medical director of New Jersey Spine Institute in Bedminster, told Becker’s that prior authorization alone requires dedicated employees, while billing and collections have become increasingly laborious and costly. Those expenses are part of a wider imbalance spine leaders have identified between reimbursement and the cost of delivering care. Todd Albert, MD, surgeon-in-chief emeritus at New York City-based Hospital for Special Surgery, described the biggest financial pressure as “the widening gap between the cost of delivering high-quality care and reimbursement.”
13% say there is no breaking point
Not every respondent sees leaving Medicare as an option.
Thirteen percent said nothing would cause them to stop accepting the program. Actual physician opt-out remains uncommon: A 2023 KFF analysis found 1.1% of nonpediatric physicians had formally opted out of Medicare.
Leaving Medicare also carries practical limitations. Patient demographics, geography, competition and the availability of patients able to pay privately can all affect whether an insurance-free model is viable. That makes the poll less a prediction of a widespread Medicare exit than a snapshot of where respondents say the pressure is greatest.
Among the choices presented, further payment cuts stand out as the clearest potential breaking point, with prior authorization and administrative burden adding to the pressure surrounding Medicare participation.
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.
