Spine surgery has been operating under significant pressure for decades, and in today’s environment, those forces continue to accelerate. Rising administrative demands, expanding prior authorization hurdles, increasing operating costs, and persistent reimbursement decline have created a landscape where surgeons are expected to manage more complexity with fewer resources. With the looming 2027 CMS Physician Fee Schedule Proposed Rule (CMS‑1848‑P), the specialty is preparing for additional reimbursement cuts that further strain the resources required to deliver complex spine care. The specialty is no longer experiencing gradual change; it is being reshaped by it.
Declining reimbursement has become a defining feature of musculoskeletal care, while operating costs rise each year and documentation requirements continue to expand. Outpatient‑eligible spine procedures have climbed steadily since 2021, setting a pace that many practices are finding difficult to adjust to. At the same time, administrative burden continues to intensify, prior authorization delays and denials interrupt care, peer‑to‑peer calls disrupt established workflows, and expanding documentation requirements add yet another layer of strain. Over time, this accumulation of nonclinical demands carries a significant hidden cost, limits access, reduces efficiency, and stretches the clinical workforce beyond sustainable capacity.
Recent commentary from the International Society for the Advancement of Spine Surgery illustrates a growing concern in spine care which is that current valuation methods often fail to capture the full scope of physician responsibility. Spine surgery involves far more than time in the operating room and requires complex judgment, technical precision, and accountability across the entire episode of care. When payment policy focuses too narrowly on duration or simplified comparisons, it overlooks the depth of work involved and contributes to the long‑term erosion of appropriate valuation.
ISASS’ commentary underscores the challenges in accurately valuing physician work, and those concerns are emerging at a time when physicians are also working to ramp up ASC clinical and operational teams to adjust to the increasing volume of outpatient spine care they are being asked to deliver.
For appropriately selected patients, outpatient spine surgery is safe, efficient and often preferred, but the shift brings new responsibilities that fall largely on surgeons and ASC teams. They must manage resource utilization, invest in specialized training and absorb unreimbursed education and patient care that were once supported within hospital systems. Facility efficiencies do not lessen physician responsibility; in many cases, they increase it. Yet payment policy often interprets the efficiencies of outpatient migration as reductions in physician work, even though the surgeon’s responsibility remains the same, and in many cases increases, thereby adding another layer to the compression already felt across the specialty.
Taken together, these dynamics create a specialty being asked to deliver more value with fewer resources. Surgeons are accountable for outcomes, cost, efficiency, patient experience and episode‑level performance. They are expected to adopt new technologies responsibly, maintain access for increasingly complex patients and navigate payer rules that shift constantly. But the system surrounding them is not evolving at the same pace. Without structural change, spine surgery risks being defined more by external constraints than by clinical expertise.
However, these same pressures create an opportunity to build a new model of care, one where physicians work alongside multidisciplinary teams to guide patients through the entire longitudinal episode while preserving surgeon autonomy. Specialist‑led care reflects this approach by aligning clinical expertise with modern delivery realities and centering decision‑making with the individuals closest to the patient, the spine surgeon.
Surgeons understand the full care continuum, from diagnosis and triage to surgical planning, postoperative management, and long‑term recovery, and they know where variation occurs and where systems help or hinder progress. By structuring care around these realities, specialist‑led care can reduce fragmentation, improve access, strengthen autonomy and create a sustainable foundation for both private practice and health system environments. It is not about doing more; it is about organizing care in a way that supports what patients need and gives surgeons the infrastructure required to deliver high‑value outcomes.
The compression era is real, and it is accelerating, but it does not have to define the future of spine surgery. It can serve as the catalyst for a new model built around clinical expertise, coordinated pathways, and outcomes that reflect what patients value most. The next part of this series will examine how specialist‑led care can be built at scale, and why the infrastructure behind it can shape the next era of spine care.
Dr. Phillips is an orthopedic spine surgeon at Midwest Orthopaedics at Rush University in Chicago; Dr. Moss is professor and chair of the department of orthopaedic surgery at the University of Connecticut in Farmington; Dr. Massel is a spine surgeon in the department of orthopaedics at Endeavor Health in Skokie, Ill.; Ms. Jacoby is CEO of Denver-based healthcare consulting firm VectorMedicalGroup; and Mr. Reid is founder and operator of Marney Reid Consulting in Cornelius, N.C.
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.
