As CMS rates dip, is there a last straw for spine surgeons?


Declining CMS pay has been a point of pain for many spine surgeons. Five spine surgeons share their concerns and if the decreasing pay rates would ever affect the patients they treat.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: Do you listen to music in the OR? If so, which albums or songs do you like best?

Please send responses to Carly Behm at by 5 p.m. CDT Wednesday, Sept. 13.

Editor's note: Responses were lightly edited for clarity and length.

Question: With CMS pay cuts continuing, would dropping Medicare patients ever be a consideration? If so, what would be your last straw?

Chester Donnally, MD. Texas Spine Consultants (Dallas): I'm still early in my career, so I don't anticipate dropping Medicare for myself. Another problem with young doctors is that we simply don't know any better when it comes to CMS prices. We think the current situation is "baseline" and pretty good but in reality, those with a little more experience know that used to be a lot better! We work very hard in a very stressful field. When I talk to my friends about the stresses of their day, their "stress" is whether or not they made other people more money that week. As a spine surgeon our stress is completely changing someone's life for the better or worse. Our care has a huge (sometimes) irreversible impact on people. I think at some point spine surgeons lost the narrative and became the bad guys in spine care and back pain. People are afraid of our services and also CMS undervalues us. It shouldn't be that way.

There is an amazing lecture from Alexandre Rasouli, MD, on Seattle Spine Foundation that highlights this point that I encourage every spine surgeon to watch. Essentially, it's also talking about how we need to unify.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I have researched this extensively. There are a handful of surgeons who have stopped taking Medicare. We never drop patients. The transition would involve making sure the patients were informed that we will still see them, with payment upon services rendered. We would educate them that their Medicare still covers testing, physical therapy, etc. I do think the number of surgeons no longer accepting Medicare assignments and not dealing with the "stick" of CMS' "carrot and stick" philosophy that started with "quality improvement" and MACRA/MIPS program that they have yet to demonstrate improved healthcare at all. That is very tempting indeed. I imagine CMS will simply vilify those physicians. In the end, CMS made the call and should look in the mirror to see why healthcare isn't any better or cheaper. 

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): We continue to see Medicare patients in our office and to provide physical therapy and interventional pain procedures. If a Medicare patient requires surgical intervention, we refer those patients. Doing those cases is a cash loss for our practice. With the cost of overhead, whether payroll or other fixed costs, taking up an ever-larger part of margin, it simply is not possible to provide care at a loss and remain solvent.

Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Pay cuts continue to get worse each year. Last year, we had a 2 percent pay cut, and this year we are looking at an additional 3.4 percent. Rising inflation and decreasing reimbursements are exacerbating stress on providers. Medicare Advantage programs are also implementing a lot of onerous prior authorization requirements, which limit patients' ability to get treatment. They are also slashing reimbursements for certain examinations and injections. There is a bill in Congress right now to tie Medicare rates to the Medicare Economic Index as introduced in bipartisan legislation. I'm hopeful this will alleviate challenges providers are facing, so we can continue to provide needed care to Medicare patients — which is of course why we got into practicing medicine in the first place.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As a long-term health system employee, the Medicare/Medicaid population is a core patient directive and will remain that way. It is truly a community service imperative to care for these folks, as many are so appreciative and gratified with all circumstances of the past many years. Reimbursements will continue to marginate to both hospital and practitioner alike, but caring for these patients is a responsible and dutiful fulfillment. Exemption of care for profit margin is noted and remembered among physician and healthcare providers.

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