The hardest spine operations can require extensive planning, hours in the operating room and significant resources before and after surgery. But the systems that pay for that care do not always recognize what makes one case substantially more complex than another.
For Richard Menger, MD, that disconnect has consequences beyond reimbursement. As economic pressure builds, the incentives can begin to influence which procedures are sustainable, where they are performed and even which patients surgeons are most likely to treat.
Dr. Menger sees that tension from two sides. He is chief of complex spine surgery, vice chair of neurosurgery and director of the USA Health Spine Institute at Mobile, Ala.-based USA Health, and his research focuses on the intersection of policy, economics and spine surgery.
“Whatever you incentivize, you’ll get more of,” Dr. Menger told Becker’s.
The complexity reimbursement doesn’t always see
Dr. Menger sees two major friction points in complex spine care.
The first is hospital reimbursement. Diagnosis-related groups can account for factors such as patient comorbidities and elements of a procedure, but he said they do not necessarily capture the severity of a spinal deformity or the technical demands of correcting it.
“The way those diagnosis groups are put together is based on different surgery types, but they don’t necessarily capture the complexity of the cases,” he said.
The second pressure occurs outside the operating room. Prior authorization can affect access to surgery, but Dr. Menger said it can also complicate physical therapy, inpatient rehabilitation, home health services and durable medical equipment afterward.
“The non-glamorous but essential parts of what we do have become really difficult,” he said.
The economics change when the horizon gets longer
USA Health has built a complex deformity program designed to give patients in South Alabama and the Gulf Coast access to care within the region. Sustaining that kind of program, Dr. Menger said, requires looking beyond the economics of an individual operation.
Operating room time, instrumentation and biologics make complex reconstruction expensive. But physical therapy, bone health, prehabilitation, medical consultations, imaging and postoperative care extend the relationship between the patient and health system.
“The time horizon matters,” Dr. Menger said. There is also a mission beyond the margin on an individual case. “We’re here to serve the community,” he said.
For Dr. Menger, the viability of complex spine care therefore depends on more than the economics of the operating room. It depends on whether an institution can support the broader continuum of care around those patients.
When incentives reach patient selection
The stakes become more complicated as healthcare places greater emphasis on outcomes and value. Reward better outcomes, return to work and other measurable results, and Dr. Menger sees a potential unintended consequence.
“You’re going to see surgeon selection favoring patients that are maybe more predestined to do well,” he said.
Some of that overlaps with legitimate clinical optimization. Smoking, diabetes control and body mass index can factor into whether a patient is ready for major surgery. But incentives designed to improve outcomes can also influence which patients enter the system.
“You’re going to get more good outcomes,” Dr. Menger said, “but it’s going to happen in organic and inorganic ways.”
Finite resources can create more direct constraints. In pediatric deformity care, for example, he pointed to expensive technologies such as magnetic growing rods as an area where limited budgets can force difficult decisions.
Reimbursement policy, in other words, can eventually reach the choices surrounding care itself.
CMS is recognizing complexity, but a gap remains
Dr. Menger sees some signs of progress. He pointed to CMS’s fiscal year 2027 inpatient reimbursement rule, which created three new Medicare severity diagnosis-related groups, MS-DRGs 523, 524 and 525, for extensive or complex spinal fusion procedures, effective Oct. 1, 2026, as evidence the agency is beginning to recognize some of the resources these operations require.
But he does not believe the problem has been fully solved. The structure still may not capture the revision nature or technical difficulty of some of the most demanding deformity operations, he said. And changes recognizing complexity on the hospital side do not necessarily account for the additional work required of the surgeon.
“There are DRG changes to help the hospital,” Dr. Menger said. “There’s no CPT code to help the surgeon who’s putting a tremendous amount of energy and thought into trying to do that case correctly.”
If the payment system does not recognize that difference, he believes the incentives can favor more reproducible, straightforward procedures over the most complex operations.
Spine care will follow the incentives
Dr. Menger expects reimbursement pressure to influence not only which procedures surgeons perform, but where and how they deliver them.
He pointed to lower-extremity surgery, where payment pressures and bundled models have helped move procedures outside hospitals and increased physicians’ interest in ancillary revenue opportunities. He expects some of the same forces to reach spine.
“I think you’re going to see different surgeries pushed outpatient,” he said. “You’re going to see different ancillary streams develop, and you’re going to see a change in how we deliver care.”
Some of that evolution can improve efficiency. But payment changes also produce responses throughout the delivery system.
“If you’re going to take away incentives to do certain surgeries, you’re going to have fewer of those surgeries,” Dr. Menger said.
That poses a particular challenge for complex spine cases that cannot simply migrate to lower-cost settings.
If surgeons aren’t at the table
Dr. Menger’s larger concern extends beyond reimbursement. Spine surgeons are trained to focus on their patients, the operating room and the technical nuances of surgery. But many forces shaping their ability to deliver that care are being decided elsewhere.
“If spine surgeons aren’t part of that conversation, it can be a little bit difficult because other people are going to start making those decisions,” he said.
Consolidation adds another layer. As hospitals merge and more physicians become employed, Dr. Menger worries the physician and patient voice can become muted, particularly in regions with few competing health systems. That can affect decisions ranging from technology adoption to lobbying for the smaller things patients need.
The technical capabilities of spine surgery will continue to advance. But whether surgeons can deliver the most complex care will increasingly depend on the economic and policy structures surrounding it.
Those decisions will be made either way. For Dr. Menger, the question is how much of a voice surgeons will have in making them.
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.
