CMS released its final rule for the 2027 Medicare physician fee schedule Nov. 4, cutting the conversion factor 2.31% to $32.63 for most clinicians — deeper than the 1.68% cut the agency proposed in July. The final rule did scale back two of the most contested proposals: It shrank the same-day visit payment reduction from 50% to 20% and softened proposed cuts to joint replacement procedures. Most provisions take effect Jan. 1.
The American Association of Orthopaedic Surgeons welcomed CMS’ decision to reduce proposed cuts to total hip, knee and shoulder replacement procedures by nearly 50% but warned the remaining cuts could worsen workforce shortages and called for broader physician payment reform.
Becker’s connected with 22 physicians and industry leaders about the final rule. Though many credited CMS for softening the joint replacement and same-day visit cuts, most said the rule extends a yearslong decline in Medicare reimbursement that is pushing independent practices toward consolidation, alternative payment models and, in some cases, out of Medicare altogether.
The question: The 2027 physician fee schedule is finalized. What is your reaction, and how will it affect both your practice and the industry at large?
Editor’s note: Responses have been lightly edited for clarity and length.
Gregory Byrd, MD. Orthopedic Surgeon at Olympia (Wash) Orthopaedic Associates: The proposal and the final rule have made cuts to reimbursement unprecedented in the percent decrease. While less than proposed, the combination of the threat and the end results has forced physicians and practices to critically look at their practices and what is tolerable. Smaller cuts could be absorbed and physicians could work a little harder. The current cuts placed means you can’t simply work harder to accommodate those cuts. This has also created a moral injury and feeling of underappreciation and devaluation of our work that is also nearly irreparable. Accordingly, we are now forced to critically look at how we deliver care and care for ourselves and look at making changes in our practice that were unfathomable years ago. These are decisions that businesses make all the time, but physicians have been avoiding because of our general altruism and self-sacrificing and people-pleasing tendencies.
We have seen yet again how Washington favors who pays them through lobbying. Hospitals and insurance companies continue to make more as they cut physician reimbursement. Time and time again we have seen that physician-driven and -led care provides the best care, but because we don’t have the same lobbying power, you see the politicians and government officials choose their friends and financial backers over patient care and physicians.
Physicians and groups are now critically looking at what their practice would look like without CMS. The government is burdensome to deal with, and the increase in Medicare Advantage plans has further increased this burden and made care delivery more difficult for this patient population to create increased profits for insurance companies.
These actions have forced conversations that were long overdue, and the ramifications will not likely be felt immediately, but slowly over the next couple of years. Unfortunately, the long-term losers will likely be the Medicare beneficiaries that just want care from a program they paid into their entire lives.
There is no other profession that has historically made less year over year for the same thing. All this and we are unable to increase our prices and just have to take what Medicare pays. Physicians are more and more questioning this model and if they want to opt in.
Harel Deutsch, MD. Co-Director of Rush Spine Center at Rush University Medical Center (Chicago): I am not surprised. CMS has been drastically reducing physician reimbursement for the last few decades. Reduced payments, plus inflation and increased practice costs, are a war against private practice for physicians and make the employment model for physician care inevitable.
Travis Doering, MD. Orthopedic Hand, Upper Extremity and Peripheral Nerve Surgeon at Upper Extremity ATX (Austin, Texas): This is my first fee schedule update as a practice owner, and it feels very different when you’re the one making payroll. A cut on top of rising rent, staff and supply costs is hard enough. What troubles me more is not knowing where CMS wants us to go. Each year brings new adjustments and new priorities, and it’s difficult to make long-term decisions for a practice when the direction keeps shifting.
The hardest part is the moral injury. I went into medicine to take care of people, and Medicare patients are often the ones who need the most time and coordination. When payment falls further behind the cost of providing that care, it gets harder to give them the care they deserve.
For my practice, the answer is to stay nimble: watch what’s changing, adapt quickly and never assume last year’s model still works. But there’s a limit. You can only make operations so efficient before patient care starts to suffer. Across the industry, I worry that more independent practices will reach that limit, and that patients will lose access as a result.
Corinne Ehretsman. CEO of CE Strategy (Cleveland Heights, Ohio): While CMS softened some of the proposed reductions, the 2027 Medicare physician fee schedule places additional financial pressure on an already challenged healthcare delivery model. The response cannot simply be to ask physicians to do more. Healthcare organizations need to rethink how they design clinical practices and deploy their resources to create greater value.
Changes to reimbursement and relative value unit valuations also challenge the assumptions underlying physician productivity expectations and compensation models. Physician productivity is not simply a function of individual effort. It is heavily influenced by how we allocate physician time, structure clinical teams, manage surgical capacity and navigate patients to the appropriate care setting. We need to optimize the practice, not just the physical space. Increasing volume or utilization does not necessarily improve financial performance, particularly when those measures fail to account for clinical complexity and contribution margin. That means aligning physician productivity expectations and compensation with their contributions to the performance of the practice and organization as a whole.
Equally important is a clear service-line strategy, informed by market demand and financial performance, that defines where to invest for growth, where to sustain services and where to reimagine the care delivery model. The continued migration of surgical cases to ambulatory surgery centers reinforces the importance of these decisions. Moving cases does not automatically create financial value. Organizations must be intentional about how they distribute surgical volume and allocate capacity across facilities, recognizing that moving lower-acuity procedures to ASCs also requires a strategy for the hospital capacity and costs left behind.
Service-line strategy establishes where an organization needs to go, while service-line maturity reflects its ability to execute that strategy and sustain performance over time. This requires the leadership, governance and operational capabilities to translate strategic decisions into measurable results. In my experience, this is where the PwC team brings significant value, helping healthcare organizations strengthen these capabilities to achieve their clinical and financial objectives.
While service-line strategy establishes where an organization needs to go, successful execution requires the leadership, governance and operational capabilities to translate that strategy into sustained results. In my experience, this is where the PwC team brings significant value, helping healthcare organizations strengthen these capabilities to achieve their clinical and financial objectives.
Alejandro Fernandez. CEO of Synergy Orthopedic Specialists (San Diego): In my opinion, you cannot cost-cut your way through a reduction in reimbursement every year. AI offers some efficiencies we are actively exploring, but the structural answer is scale and integration.
Synergy Orthopedic Specialists has an ASC, durable medical equipment, physical therapy, advanced imaging and anesthesia, alongside the group’s surgical and nonsurgical specialties, serving a market of roughly 3 million people across San Diego and neighboring counties.
The ASC, ancillary services and operational discipline enable an independent group to absorb these reductions without turning away Medicare patients. For Synergy in San Diego, the response is not to cut access — it is to own more of integrated care delivery.
The reality is familiar: another year, another cut into inflation. A 2.31% reduction in the conversion factor, down to $32.63, is deeper than CMS proposed in July, and most of it is simply Congress letting the 2026 bump expire. That 2.31% applies to everything.
For orthopedics, the real story sits at the procedure level, and these specialties are getting beaten up:
- Total hip and knee replacements (CPT 27130 and 27447): Across 2026 and 2027, the work value of these procedures has fallen roughly 20% — a 7.5% cut in 2026 and about 13% more in 2027. Close to a fifth of the professional value of a hip or knee replacement, gone in two years.
- Office visit billed with an injection (zero-day procedures): The second service is paid at 80%, a 20% reduction. Joint and spinal injections are zero-day, so everyday ortho and spine visit-plus-injection pairings take the hit.
These cuts also do what they always do. Physicians get worried and look to employment and consolidation, because scale and ancillaries are how they survive — and the income gap between well-structured groups and exposed ones keeps growing.
I call orthopedic surgeons the carpenters of medicine. At this rate, the carpenter who frames your house will soon out-earn the one who rebuilds your knee.
Thomas Fondren. CEO of Advanced Orthopedics of Oklahoma (Tulsa, Okla.): My reaction is that we keep getting the same rule with new numbers. Most physicians will see a 2.31% conversion factor cut, which is greater than CMS proposed in July. And last year’s 2.5% bump from Congress was a one-time fix that’s now gone.
The budget neutrality rule is the root cause, and until it changes, nothing else will. Every time CMS decides to value something more, independent practices pay for it. For example, same-day evaluation and management services with a procedure take a 20% reduction. In pain and spine, that’s a lot of our injection visits.
Most facilities get an annual inflation update. We don’t. Every year our costs go up, our Medicare rates go down, and commercial contracts pegged to Medicare rates follow them down. Then people wonder why independent practices keep selling to health systems and private equity. The policy is pushing them there.
I know a lot of very smart practice administrators who are being forced to make hard decisions about staffing, service lines and whether to sell, and they didn’t create any of these problems. It’s not for lack of trying. These are people who’ve cut overhead, fought denials, renegotiated contracts and built new revenue streams. The model is working against them. You can only run so fast on a treadmill that keeps speeding up. And when the numbers don’t work, it’s usually the CEO or CFO who gets replaced, even when they did everything right. The margins of three to five years ago aren’t returning under this model.
For our practice, the answer is to keep diversifying: ancillaries, direct contracts with employers and anything that reduces how much we depend on the Medicare fee schedule. But that’s a workaround, not a fix.
The real fix has to come from Congress. Tie physician payment to inflation the same way hospitals’ is, and reform budget neutrality so one specialty’s increase doesn’t come out of another specialty’s pocket. Until then, we’ll be writing this same answer every November.
Megan Friedman, DO. Chief of Anesthesiology at Adventist Health Southern California (Roseville, Calif.) and Pacific Coast Anesthesia (Los Angeles): While it is encouraging that CMS softened some of the proposed reductions to joint replacement reimbursement, the overall direction remains concerning. Physician practices and surgical facilities continue to face rising labor and operational costs, while Medicare reimbursement fails to keep pace.
One of the fundamental challenges is that reimbursement is largely tied to individual procedures, while the cost of delivering surgical care extends well beyond the time spent performing a case. Hospitals and ASCs must maintain anesthesia coverage, nursing staff and other perioperative resources throughout the day to accommodate scheduled procedures, add-on cases and unexpected changes in the surgical schedule. Those costs exist regardless of how many procedures are ultimately performed.
As reimbursement continues to decline relative to operating costs, the financial pressure increasingly falls on hospitals and ASCs, many of which already operate on narrow margins. Over time, this threatens the sustainability of surgical services, limits opportunities for growth and ultimately affects patient access to care.
Tyler Goldberg, MD. CEO of the North American Orthopedic Concierge Association (Austin, Texas): The 2027 Medicare Physician Fee Schedule is another example of a predictable and unsustainable cycle. CMS proposes dramatic reimbursement cuts, physicians mobilize, professional societies advocate and the final reductions are softened. We then celebrate losing less than originally proposed.
I applaud our professional organizations for their advocacy, but advocacy may change the size of the cut; it hasn’t changed the direction of travel.
For independent surgeons like me, these reductions accelerate the need to rethink our business models. Three years ago, I incorporated concierge services into my traditional orthopedic practice. It has fundamentally transformed how I practice and reduced my dependence on third-party reimbursement.
The greatest threat to our profession isn’t any single reimbursement cut. It’s continuing to operate under a model where someone else unilaterally determines the value of our work.
Surgeons must continue advocating, but we also need to innovate. At some point, the answer isn’t playing the same game harder. It’s playing a different game.
Brandon Hirsch, MD. Orthopedic Spine Surgeon at Disc Sports and Spine Center (Newport Beach, Calif.): The finalized 2027 Medicare physician fee schedule — featuring a deeper 2.31% cut to the conversion factor — confirms a troubling long-term reality: Federal policy continues to drive healthcare delivery away from independent practice and toward vertically integrated health systems.
While framed as cost containment, perpetual reductions to professional fees do not lower overall healthcare spending. Instead, they actively accelerate consolidation and increase total system costs.
Independent practices absorb mandatory fee cuts while bearing the full cost of inflation, overhead and staff salaries. In contrast, vertically integrated hospital systems are heavily subsidized by outpatient facility fees, allowing them to bill significantly higher total amounts for the exact same clinical services.
Squeezing independent margins makes private practice economically unsustainable. As independent physicians are forced into hospital employment, regional competition declines, market dominance increases and overall healthcare expenditures rise.
Ultimately, this rule confirms that the government is not interested in reducing healthcare costs by making independent practice economically feasible. For my practice, these compounding pressures make exiting Medicare participation in 2028 a certainty.
Vamsi Kancherla, MD. Spine Surgeon at Specialty Orthopaedics (Gainesville, Ga.): The final conversion factor cut to $32.63 is the part that hits hardest. Most of it is simply last year’s temporary increase expiring, but it still leaves practices with less money while costs keep rising. For spine, where Medicare patients make up a large share of what we do, that adds up. I do appreciate that CMS moderated the joint replacement reductions and narrowed the same-day visit cut to 20% on zero-day procedures, though the remaining pressure still creates extra friction around office-based injections and minor procedures.
In our practice, that means we’ll have to be careful with certain same-day visits so patients aren’t forced into extra trips. At the same time, the lower baseline makes it harder to keep investing in the endoscopic and minimally invasive techniques that allow less tissue disruption and quicker recovery. Repeated cuts like this continue to favor larger systems and make it tougher for independent practices to stay independent while still offering the newer options patients increasingly ask for.
We’re still going to take care of our patients the best way we know how. It just gets more complicated when the payment for that care keeps sliding while the cost of delivering it doesn’t. Congress needs to step in with a more stable, predictable update — something tied to actual practice cost inflation — so independent practices can keep focusing on better care instead of simply absorbing the next cut.
Jessica Lam, PhD. Practice Manager at Pacific Coast Anesthesia (Los Angeles): From an operations perspective, the biggest concern is the growing gap between reimbursement and the cost of staffing anesthesia services. Recruiting and retaining anesthesiologists remains expensive, and declining reimbursement makes it increasingly difficult for independent anesthesia groups to remain financially sustainable. Hospitals and surgery centers still need reliable anesthesia coverage to keep their operating rooms running, regardless of how many cases are scheduled on a given day. When professional reimbursement falls short of covering those staffing costs, facilities are increasingly expected to make up the difference, even as many surgery centers operate on razor-thin margins. This puts pressure on both anesthesia groups and the facilities they serve, with potential consequences for surgical capacity and patient access.
Cheraire Lyons. President of Revenue Cycle Operations at InSource Provider Services (Atlanta): The final rule presents a mixed financial outlook for spine practices. ASC reimbursement for core interventional pain procedures, including transforaminal epidural steroid injections, facet injections and radiofrequency ablations, will decline by approximately 3% to 4%, while physician reimbursement will decrease by 2.31%, creating meaningful pressure on practices heavily dependent on site-of-service revenue. However, CMS tempered these reductions through several favorable policy decisions. CMS eliminated the proposed 50% multiple-procedure discount for emerging therapies such as spinal cord stimulation and peripheral nerve stimulation services, preserving reimbursement for multilevel emerging therapy spinal procedures. CMS also finalized an 80% reimbursement rate, rather than the proposed 50%, for same-day E/M and procedural services. As reimbursement continues to shift, leading spine practices will need to balance margin compression in traditional pain management services with strategic growth in emerging therapy spinal procedures, operational efficiency and same-day care models to sustain profitability and support long-term practice growth.
Robert Masson, MD. Founder and Chairman of Masson Spine Institute (Orlando, Fla.): No single line in this rule is catastrophic. That is the problem. A 2.31% cut to the conversion factor, a 13% cut to joint replacement instead of 20%, a 20% cut to same-day visits instead of 50%, a 5% annual cap on overhead cuts that CMS itself says will fall hardest on neurosurgery and orthopedics, and a clear signal that global surgery payments are next. Each one is presented as modest or as a concession. Taken together, year after year, it is death by a thousand cuts to the delivery of quality, patient-centric care.
What is missing from the entire conversation is what this care is for. We are entering an era where we expect everyone to live longer. By 2030, one in six people worldwide will be over 60. The question is no longer whether people will reach 80 or 90. It is whether they will reach it mobile, independent and productive, or in a chair. Musculoskeletal disease is the single largest driver of that answer. Spine and joint disorders are already the leading cause of disability in the world, and they are the difference between a 70-year-old who is still working, playing with grandchildren and contributing, and one who has quietly been subtracted from the economy and from their own life. Healthy longevity is not a wellness slogan. It is a musculoskeletal problem, and spine and orthopedic surgery are the front line.
Against that backdrop, CMS has just told the surgeons who restore that function that their work is worth less again this year. Patient-centric care has a cost structure. It means time in the room, a surgeon who follows the patient through recovery, a stable team, and the ability to invest in the tools and training that make surgery less destructive and recovery faster. Every cut is absorbed somewhere, and it is absorbed in exactly the places that determine whether a patient gets their life back: fewer minutes, more fragmented visits, less investment, more volume per surgeon just to stand still. The same-day visit policy is a good example. The incentive now is to bring a 75-year-old back on a second day for an injection that could have been done on the first. That is not efficiency. That is paying for a worse experience.
For my own practice, the honest answer is that this rule does not change much, because I made the decision two years ago to opt out of Medicare. Masson Spine Institute is a boutique outpatient spine practice built on direct pay and employer-directed bundles, in a surgery center I own, and it is organized entirely around one outcome: returning people to functional performance so they can keep living purposefully. I did not leave because of one rule. I left because I could see the trajectory, and I did not want the care I deliver to be dictated by a formula that has no line item for whether the patient got their life back.
For the industry, more surgeons will reach the same conclusion. Independent practices will keep migrating to cash, bundles and employer-direct contracts, or they will sell to a health system that is now being paid substantially more for the same work. Either way, the Medicare patient, the very population at the center of the longevity question, loses access to the most experienced surgeons. CMS says it wants care in lower-cost settings. The math in this rule pushes the other way.
The way out is not another year of comment letters arguing over RVUs. It is payment tied to measured functional outcomes and transparent episode pricing, where a surgeon who delivers a faster, cleaner return to life is rewarded for it. If we are serious about a world where people live longer, we have to be serious about paying for the care that lets them live well.
Lori Pagan. CEO of Orthopaedics Northeast (Fort Wayne, Ind.): While we appreciate that CMS moderated some of the proposed reductions to joint replacement procedures and same-day visits, the finalized 2027 Medicare Physician Fee Schedule continues to place additional pressure on independent orthopedic practices.
At Ortho Northeast, we remain committed to delivering high-quality, accessible and cost-effective care while managing the increasing costs of staffing, employee benefits, technology and regulatory requirements. These are essential investments in our patients and our workforce, yet reimbursement has not consistently kept pace with the cost of delivering care.
What concerns me most is that continued reimbursement reductions threaten the very practices that play an important role in controlling healthcare costs. Independent physician practices have demonstrated the ability to deliver high-quality care in lower-cost settings, often with greater efficiency and more personalized patient experiences than larger hospital-based systems. Preserving these practices is not simply about maintaining physician independence; it is about protecting a model of care that benefits patients, employers and the healthcare system as a whole.
If reimbursement policies continue to make independent practice increasingly difficult, we risk accelerating consolidation, reducing competition and ultimately driving healthcare costs higher. That outcome runs counter to the broader goal of making healthcare more affordable.
As an industry, we need reimbursement policies that recognize the value independent practices bring to the healthcare system. Reducing reimbursement to providers who are helping deliver high-quality care at a lower cost is not a sustainable strategy for improving healthcare affordability or preserving patient choice.
Adamina Podraza, MD. Medical Director of Deerpath Ambulatory Surgical Center and Chair of the Department of Anesthesia at [ORGANIZATION TK] (Morris, Ill.): [CMS continues] asking physicians to deliver high-quality care with improving outcomes when they’re already dealing with increasing operating overhead and administrative burden. We can’t continue to improve care without appropriate reimbursement for expensive new technology.
Praveen Reddy, MD. CEO of Center for Minimally Invasive Neurosurgery (Houston): As a neurosurgeon in independent private practice, I find the 2027 final rule incredibly disheartening.
The baseline 2.31% cut to the conversion factor, compounding decades of inflation-unadjusted pay declines, is unsustainable for independent specialty care. What stands out as particularly damaging to neurosurgery is the 20% penalty on Modifier 25 same-day services. In our field, when a patient presents with severe, acute pain, performing a same-day minor procedure or injection is standard, compassionate care that saves the patient an extra trip and unnecessary suffering. Penalizing practices for providing efficient, single-visit care forces a terrible choice: Absorb severe financial losses or intentionally delay patient care across multiple appointments.
Ultimately, these continuous cuts don’t save the system money; they simply accelerate the destruction of independent private practices. It pushes more community neurosurgeons into hospital employment, driving up consolidated facility costs and severely restricting patient access to timely, specialized surgical evaluations. In the end, it will only drive costs up and not down.
Ben Schwartz, MD. Senior Advisor at Commons Clinic (Los Angeles): My reaction to the physician fee schedule is more of the same, only worse for joint replacement surgeons. While the cut was softened somewhat (from an initial proposal of about 20% down to about 13%), this still represents another year of double-digit decline. I jumped off the joint replacement treadmill a little over a year ago, but I think we will see the industry react differently than in the past. Surgeons and their professional organizations will continue advocacy efforts, but now realize that alternative solutions are the more realistic path. That includes meaningful ASC ownership stakes, direct contracting, physician-led bundled payments, cash pay and follow-through on Medicare opt-outs. I personally sense a shift among joint replacement surgeons who have finally accepted that the only way to win the game is not to play it.
Lali Sekhon, MD. Surgeon at Reno Orthopedic Center (Reno, Nev.): The better we get, the less we get paid. The only industry that pays less as your career progresses and your expertise and efficiency improve.
When surgeons are quiet quitting, when surgeons don’t want to take high-risk cases, when patients wait six months to see a specialist, when the best and brightest don’t enter medicine, we need to remember these cuts. Right now I pay my plumber more on a weekend to fix my blocked toilet than I would pay my orthopedic surgeon to replace my hip or knee. This will destroy private practice, and the hospital-employed docs, with less incentive to get the work done, will take over.
James Stoll, MD, Surgeon at Midwest Spine Center (Glendale, Wis.): As a 40-year veteran orthopedic spine surgeon, I have two reactions to this proposal:
- How many more reductions will be necessary before orthopedics and spine cannot be sustained as every case is for a loss?
- Why is the government forcing a category of physicians to be employed, looking for more predictable revenue streams?
If you hit your thumbnail with a hammer, it hurts. After the third, fourth and fifth?
Jared Torkelson, PA-C, DMSc, Board President of the American Society of Osteoporosis Providers (Mankato, Minn.): A 2.31% cut to the conversion factor, down to $32.63, lands on practices that are already short on staff. CMS deserves credit for listening on joint replacement. Setting hip and knee work RVUs at the American Medical Association’s Relative Value Scale Update Committee value of 16.70 is far better than the July proposal. It is still a cut.
The change I will feel most in clinic is the same-day visit reduction. In orthopedics, physician assistants and nurse practitioners often evaluate a patient and give a joint injection in the same visit. Paying the second service at 80% penalizes efficient care that saves patients a second trip.
I am encouraged that CMS is paying more for longitudinal care. That matters for bone health. Osteoporosis care and fracture prevention are built on years of follow-up, not one-time procedures. If Medicare wants fewer hip fractures, it has to keep that work viable.
AJ Yates, MD. Professor and Vice Chair for Quality, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine; Chief of Orthopaedic Surgery at UPMC Shadyside (Pittsburgh): Physician payment reform is needed both in the short and long term.
The 2027 physician fee schedule final rule retained significant cuts to total hip and knee that will drive payments to the level of or below that of Medicaid reimbursement. This will drive surgeons out of private practice and into employment through hospitals that, paradoxically, CMS was able to reward with higher reimbursement for the same cases. Coupled with the conversion factor decrease and continued failure to consider inflation, surgeon participation in Medicare will be an issue affecting an increasingly aged population. Tipping points are real; backing away from what might be an access-to-care cliff would represent a very small percentage cost out of the overall expense of lower-extremity arthroplasty.
The bigger picture is the lack of political courage in Washington to address the long-term funding of Medicare, which has been held bound by rigid spending rules despite many billions of dollars being sent overseas at executive whim. American healthcare spending is regarded as an excessive proportion of the GDP; it can be argued that growth in such spending is a natural consequence in a country that has progressed far into the postindustrial future with other needs readily met. The needed taxes and income-driven enrollment contribution changes have been laid out in bipartisan cooperation. They are waiting for the right leadership to promote their enactment so that Medicare not only survives but also can absorb the growth in medical miracles that are being discovered daily.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Health System’s Neuroscience Institute (Boise, Idaho): We are continuing to witness the creeping normality and gradual decline of a once durable and reliable healthcare system that inches closer each day to a national health service. The loss of urgency and portability, assured physician weariness and scarcity, and hospital service line forfeiture resulting as the costs far exceed current substitutive support. Declarative and forthcoming changes in the near future will not bring any relief for services rarely utilized.
The collective effect of these continued reductions to hospitals and physicians is both noticeable and expectant in their additive consequences. The trickle-down of revenue curtailments negatively affects hospital growth, technological procurements and customary services to patients and community. Spinal surgery remains enigmatic as the billing disparities for the highest-acuity patients are managed by select institutions and ignored by others.
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