Spine surgery has more treatment options than ever. Using them is getting more complicated.
Payers are reaching further into surgical planning. Medicare reimbursement remains under pressure. Surgeons are becoming more selective about fusion and which patients should reach the operating room at all. Meanwhile, new technologies are advancing faster than some training and payment structures can accommodate.
Across recent Becker’s conversations with spine leaders, those pressures repeatedly intersect, shaping not only which operations surgeons perform, but when, where and under what constraints.
1. Payers are reaching deeper into the surgical plan: Getting a fusion approved can now require more than merely establishing medical necessity.
Surgeons recently told Becker’s that some insurers are asking for exact graft and implant names, level-by-level CPT coding, imaging and detailed documentation of failed conservative treatment. Traditional Medicare has also entered the equation through CMS’ WISeR model, which includes cervical fusion among services subject to prior authorization or prepayment medical review in six states.
The requirements can also change how surgeons document their decisions. Bryce Basques, MD, director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., told Becker’s insurer algorithms can search medical records for specific terminology.
“Writing notes no longer means documenting medical decision-making,” he said.
That creates a second job after deciding an operation is appropriate: building a record capable of satisfying the payer’s criteria.
2. Medicare economics are testing the limits of participation: Reimbursement pressure is creating a more fundamental question for some surgeons: At what point does treating Medicare patients stop being sustainable?
In a recent Becker’s LinkedIn poll of 112 respondents, 53% said further payment cuts would be the factor most likely to make them reconsider Medicare participation. The concern comes as CMS’ proposed 2027 physician fee schedule would again lower the conversion factor for physicians participating and not participating in qualifying alternative payment models.
Alexander Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, has also challenged a proposed CMS efficiency adjustment affecting spine procedures.
“To say that you’re going to pay less because you’re better doesn’t make any sense in the medical economic equation,” he told Becker’s.
His broader concern is access: If reimbursement continues falling while the expense and risk surrounding complex surgery rise, fewer surgeons may be willing to take the most difficult Medicare cases.
3. Fusion is becoming a more selective decision: Fusion is not disappearing, though the threshold for using it is changing. Cervical disc replacement has matured, while decompression, endoscopy and laminoplasty are giving surgeons more opportunities to preserve motion in appropriately selected patients.
“I think that threshold for fusion is definitely becoming more selective,” Wilson Ray, MD, chief of spine surgery at Washington University School of Medicine in St. Louis, told Becker’s.
But more clinical options do not necessarily mean more accessible options. Dr. Ray pointed to hybrid cervical procedures, disc replacement at one level and fusion at another, as one area where coverage policies can lag behind surgical decision-making.
The question is increasingly not simply whether a surgeon can fuse a patient. It is whether stabilization is necessary, what the least disruptive durable operation is and whether the payer will cover it.
4. Surgeons are raising the threshold for operating at all: As the threshold for fusion changes, some surgeons are also drawing firmer lines around when any operation should happen.
Recent Becker’s conversations found surgeons declining or delaying surgery when symptoms do not correlate with imaging, conservative care has not truly been exhausted, bone health or other medical risks remain unaddressed, or the expected functional benefit does not justify the operation.
“Being a good surgeon sometimes means saying no,” Vijay Yanamadala, MD, of Hartford (Conn.) HealthCare, told Becker’s.
Outpatient migration has created another distinction. A patient may be appropriate for surgery but not for an ASC, requiring surgeons to become increasingly precise not only about whether to operate, but where.
5. Endoscopy is running into the economics of adoption: Endoscopic spine surgery illustrates another tension in the field: Clinical interest can move faster than the infrastructure supporting it.
When Becker’s recently asked 18 surgeons what is slowing adoption, physicians repeatedly pointed to reimbursement, equipment costs, institutional support and the economics of the learning curve.
“The learning curve is steep, but without a guaranteed and dedicated payment model, I don’t think many will venture down that road,” Adam Bruggeman, MD, CEO and surgeon at Texas Spine Care Center in San Antonio, said.
At the other end of the adoption curve, Ki-Eun Chang, MD, a neurosurgeon at Naval Medical Center San Diego, said 90% to 95% of his practice is now endoscopic. His experience shows what is possible once a program has institutional buy-in, a surgeon champion and a financial case for adoption.
6. Innovation is facing a higher bar for evidence and training: The pace of spine innovation is creating another pressure point: proving that training, evidence and oversight are keeping up.
The North American Spine Society released a patient safety position statement Sept. 28 calling for structured education, clinical training, supervised procedural experience and objective competency assessment before physicians independently perform spine interventions.
Pierce Nunley, MD, director of Spine Institute of Louisiana in Shreveport and a member of the task force behind the statement, put the concern plainly: “A weekend course for anything complex is simply not going to work,” he told Becker’s.
The evidence question extends to devices. Lali Sekhon, MD, PhD, a spine neurosurgeon at Reno (Nev.) Orthopedic Center, recently raised concerns after his research found substantially different collapse rates between two expandable lumbar cages.
“This may be a case of the technology being ahead of the results,” he told Becker’s.
7. Liability is becoming part of the surgical calculus: Malpractice pressure can influence decisions long before a case reaches a courtroom.
Recent Becker’s coverage has included disputes involving postoperative monitoring, timing of diagnosis and informed consent, while surgeons have described how liability concerns can influence patient selection, testing and willingness to take on high-risk procedures.
Nitin Bhatia, MD, an orthopedic spine surgeon at UCI Health in Orange, Calif., said medically complex patients sometimes “cannot get care in other settings due to the legal risk.”
The pressure could become more complicated as AI moves into postoperative monitoring. James Mooney, MD, a neurosurgeon at VCU Health in Richmond, Va., has raised questions around who is responsible for responding when an algorithm detects deterioration, another potential layer of liability for surgeons and health systems.
8. The old spine practice model is getting harder to sustain: All of these pressures eventually converge on practice economics.
Deeptee Jain, MD, a minimally invasive spine surgeon at the Center for Bone and Joint Surgery of the Palm Beaches in Royal Palm Beach, Fla., said moving from academic medicine into private practice changed how she thought about the relationship between surgical volume and financial health.
“A busy practice is not necessarily a profitable practice,” she told Becker’s. Her argument is not that surgeons should become accountants. It is that a practice built principally around performing procedures becomes harder to sustain when reimbursement tightens and the cost and administrative work surrounding those procedures continue to rise.
Other surgeons have pointed to nonoperative care, coding, bundled payments, minimally invasive surgery and cost efficiency as areas where practices may be leaving opportunities on the table.
None of these pressures exists in isolation. Payer policies influence which operations patients can access. Reimbursement affects which technologies practices can afford to adopt. Liability and safety concerns affect case selection. Greater clinical selectivity changes the economics of organizations historically built around procedural volume.
Spine surgery has more tools, techniques and treatment options than it did a decade ago. The growing challenge is navigating everything closing in around the operation.
Editor’s note regarding LinkedIn polling: Becker’s has no insights on respondents’ organizations or roles.
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