For spine surgeons, the question heading into 2027 may no longer be how to grow their practices, but what they can afford to give up.
Medicare participation, practice independence, expensive surgical technology and traditional business models are all coming under scrutiny as reimbursement pressures collide with rising operating costs and the migration of procedures to outpatient settings.
In recent conversations with Becker’s, spine leaders described increasingly difficult trade-offs between financial sustainability, physician autonomy and patient access. Their concerns reflect a broader shift across the specialty: Maintaining the status quo may be becoming as risky as changing it.
Here are five things spine surgeons may have to reconsider.
1. Medicare participation: For some spine surgeons, declining reimbursement is raising a question that once seemed unthinkable: Can they afford to keep treating Medicare patients?
“The tipping point came when each Medicare patient became a net-net loss on each and every office visit,” Brian Gantwerker, MD, neurosurgeon and president of The Craniospinal Center of Los Angeles, told Becker’s.
The concern is not hypothetical. Spine surgeon Ara Deukmedjian, MD, opted out of Medicare in 2011, while Vladimir Sinkov, MD, dropped all insurance contracts, including Medicare, in 2022. Both have continued practicing under alternative payment arrangements.
The pressure could intensify under CMS’ proposed 2027 Medicare Physician Fee Schedule, which would reduce the conversion factor by 1.68% for clinicians outside qualifying alternative payment models. Orthopedic surgery also faces an estimated 7% reduction from proposed changes to relative value units, excluding the conversion factor change.
Meanwhile, Medicare’s Ambulatory Specialty Model will introduce mandatory performance-based payment adjustments for selected specialists treating low back pain, with the first performance year beginning in 2027.
Daniel Park, MD, an orthopedic spine surgeon at Midwest Orthopaedics at Rush in Chicago, warned that smaller practices may have to reconsider whether accepting Medicare patients remains financially sustainable. A widespread Medicare exit has not materialized. But as reimbursement pressures mount, the greater concern may be a gradual erosion of access as practices limit new Medicare patients or pursue private-pay models.
2. Practice independence: Remaining independent has long offered spine surgeons greater control over clinical decisions, staffing and practice operations. But preserving that autonomy increasingly requires significant financial investment.
At Leawood, Kan.-based Kansas City Orthopedic Alliance, orthopedic spine surgeon Theodore Koreckij, MD, recently described the financial challenges of expanding an independent spine practice while competing with hospital systems for physicians.
“It’s harder and harder to compete with hospital systems for that up-front salary,” Dr. Koreckij told Becker’s. KCOA added a second spine surgeon in October, an investment Dr. Koreckij said may take three or four years to pay off. The expansion comes as the practice also invests in additional facilities and services to support its independent model.
The alternative is not necessarily easier. Selling to a health system or outside investor may offer greater financial security but can also mean surrendering influence over staffing, scheduling and care delivery.
Thomas Fondren, CEO of Advanced Orthopedics of Oklahoma in Tulsa, described that dilemma in recent comments to Becker’s. “Selling and staying independent both come with a cost,” he said.
For spine practices, independence may increasingly depend on the ability to invest in ASCs, ancillary services, recruitment and infrastructure while absorbing the financial risks that come with ownership.
3. The economics of complex spine care: As more routine spine procedures migrate to ASCs, hospitals face a difficult question: How will they sustain the most expensive and resource-intensive cases?
Keven Burns, MD, an orthopedic spine surgeon at the Spine Institute of Arizona in Scottsdale, sees minimally invasive techniques expanding the number of patients eligible for outpatient treatment. But extensive spinal reconstructions still require hospital resources, specialized personnel and costly implants.
“We have awesome technology right now, but financially, can we even implement it?” Dr. Burns told Becker’s. As appropriately selected patients undergo decompressions and limited fusions in ASCs, hospitals could be left with a greater concentration of complex procedures requiring substantial operating room time, advanced technology and prolonged postoperative care.
Wilson Ray, MD, a spine surgeon at Washington University School of Medicine in St. Louis, raised similar concerns. “As more routine, financially favorable cases move to outpatient settings, hospitals are increasingly left caring for the sickest and most complex patients while still having to support the infrastructure, staffing, research and educational missions that come with being a major medical center,” he said.
The concern is not that complex spine surgery will disappear, but that hospitals may struggle to maintain the resources needed to provide it as their case mix becomes more expensive. For surgeons and health systems, the challenge will be determining which procedures can safely move to outpatient settings while preserving access to complex care that cannot.
4. The freedom to invest in new technology: Spine surgery is experiencing rapid innovation in robotics, navigation, AI, implants and minimally invasive techniques. Yet the ability to adopt new technology is increasingly colliding with the economics of delivering care.
“There’s been an explosion of new spine technologies, many of which differ only slightly from what’s already available,” Bilal Butt, MD, a spine surgeon at Cleveland Clinic, told Becker’s.
Dr. Butt argues that new technologies must demonstrate meaningful clinical advantages rather than simply offer incremental changes to existing approaches. At Cleveland Clinic, that means evaluating whether innovations improve outcomes, make procedures more predictable or reduce the likelihood of complications and revision surgery.
The stakes are growing as practices weigh capital expenditures against declining reimbursement and competing operational needs.
Muhammad Abd-El-Barr, MD, PhD, chief of endoscopic spine surgery at Duke University Medical Center in Durham, N.C., identified the central dilemma: “The hardest decision in 2027 will be deciding what not to invest in, and having the discipline to put the needs of the entire care pathway ahead of the growth of any individual service,” he said.
5. A surgery-first business model: Perhaps the most fundamental shift is occurring beyond the operating room. As Medicare introduces greater accountability for episodes of care, spine surgeons are confronting whether a business model centered primarily on performing procedures will remain sustainable.
“The surgeon’s value is no longer just the operation. It is stewarding the entire episode,” Michael Verdon, DO, a neurosurgeon and chief medical officer of Dayton (Ohio) Neurologic Associates, told Becker’s.
Dr. Verdon argues that spine practices must take greater responsibility for the entire patient pathway, including nonsurgical treatment, rehabilitation, patient selection and outcomes tracking. That shift could require investing in services that do not directly generate surgical volume and, in some cases, may reduce the number of operations performed.
Some health systems are already pursuing more coordinated approaches.
At Richmond, Va.-based Bon Secours Mercy Health, Jed Vanichkachorn, MD, a physician and medical director of orthopedics and spine, has helped develop a “spine center without walls” designed to coordinate care across clinical settings through nurse navigation and more streamlined patient pathways.
The approach reflects a broader move toward managing the full course of spine care rather than focusing exclusively on the surgical encounter. For spine practices, that may mean giving up the assumption that more procedures necessarily translate into a stronger business.
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.
