Tying reimbursements to inflation and paying more for complex cases are two revisions that spine and orthopedic surgeons would make if they were in charge of CMS.
Reimbursements for spine and orthopedic surgery have not kept pace with the complexity or cost of delivering that care. The current structure penalizes surgeons who take on the hardest cases and the most advanced techniques, according to these two physicians who recently connected with Becker’s.
Note: Responses were lightly edited for clarity and length.
Question: If you could change one thing about how CMS reimburses spine and orthopedic surgery, what would it be? What would actually change in your practice the day it took effect?
Michael Gross, MD. Orthopedic Director of Union Middlesex Orthopedics (Woodbridge, N.J.): CMS should pay meaningfully more when a surgeon operates on a diabetic, osteoporotic, morbidly obese or immunocompromised patient, and proportionally less for a straightforward case in an otherwise healthy individual.
Right now, a one level lumbar fusion reimburses the same whether the patient is a healthy 38 year old athlete or a 71 year old with morbid obesity, poorly controlled diabetes and advanced coronary disease. The code is identical, but the operative time, technical difficulty, complication risk and postoperative management are fundamentally different.
If that change took effect, the most immediate impact would be on surgeon behavior and case mix. Surgeons would no longer be financially penalized for taking on medically complex patients. The current flat payment model quietly discourages difficult cases because reimbursement is fixed while risk, time and liability all increase. Risk adjusted payment would correct that mismatch.
It would also make preoperative optimization far more systematic. If comorbidity burden directly affects reimbursement, practices and hospitals will build better infrastructure around documenting HbA1c, DEXA findings, nutritional status, frailty and other relevant risk factors. That does not just improve coding, it drives real optimization before surgery.
At the same time, outcomes data would become more meaningful. Surgeons who treat sicker, more complex patients would no longer appear worse on paper simply because of their case mix. Performance could be viewed in the proper clinical context.
Referral patterns would likely shift as well. Tertiary and academic centers currently absorb a disproportionate share of medically complex patients, while community practices are often incentivized to favor cleaner cases. Payment should follow the complexity of care, regardless of where that care is delivered.
There are real risks to a model like this. The most obvious is upcoding, every chart could suddenly reflect “significant comorbidities,” which would require rigorous audit systems and a validated scoring method to prevent abuse. There is also the possibility that some surgeons might feel incentivized to keep patients they should still refer to higher acuity centers.
Even so, I would take that tradeoff. The current flat rate system sends the wrong signal; it consistently frames complexity as a liability. In practice, that is the opposite of how good medicine should work.
Brandon Hirsch, MD. Orthopedic Spine Surgeon DISC Surgery Center (Newport Beach, Calif.): If I could change one thing about how CMS reimburses spine and orthopedic surgery, it would be straightforward: index payments to inflation. Not a partial adjustment or a formula that erodes in practice. Full indexing.
The numbers are not ambiguous. Across orthopedic subspecialties — trauma, sports medicine, arthroplasty — inflation-adjusted Medicare reimbursement fell roughly 30% between 2000 and 2020. The compound annual rate of decline in orthopedic sports medicine was negative 2.2% per year. The Relative Value Units assigned to procedures actually went up during this period. Meanwhile, hospital outpatient reimbursement adjusted for inflation increased by over 110% between 2004 and 2024, even as the professional fee paid to the surgeon performing the work moved steadily in the opposite direction. The conversion factor simply does not move with the cost of running a practice, and patients feel that in who is willing to see them and what they are offered.
What makes this particularly striking is that patients have no idea how far the gap has grown. A systematic review of more than 4,300 surveys found that patients estimated reasonable surgeon fees at 11.2 times the actual Medicare rate, and believed actual reimbursement was 5.9 times higher than it truly is. For total hip replacement, patients perceived reimbursement to be 26 times greater than reality. The public is not accusing surgeons of being overpaid. They consistently believe we are underpaid, and still overestimate the number by a factor of six.
Three structural problems compound this. Site-neutral payment reform would stop rewarding the same procedure more generously simply because it happens in a hospital rather than an ASC, improving access to lower-cost, high-quality surgical settings. Eliminating irrational facility fees would align what the patient sees on their EOB with the work actually performed. And novel techniques like endoscopic spine surgery need reimbursement that reflects real equipment costs, not RVUs calibrated for older approaches, so patients can actually access them.
The day inflation indexing took effect, innovation and complexity would no longer come at a financial penalty to the surgeon delivering them, and patients would have broader access to the most advanced care available.
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.
