The next major failure in spine care may not begin in the operating room. It could begin when a patient in a smaller market cannot find a surgeon nearby. It could deepen when an insurer delays imaging, therapy or an operation. It could become permanent when the hospital or practice capable of taking the most complex case decides the financial and administrative exposure is no longer sustainable.
Orthopedic leaders in May told Becker’s that consolidation, shrinking autonomy, rising practice costs and a workforce that may not keep pace with demand could derail care over the next decade.
For spine care, those risks are becoming more measurable. New workforce projections point to growing neurosurgeon shortages and persistent geographic disparities. Medicare has finalized a 2.5% efficiency adjustment for many procedural services, a policy spine surgeons say undervalues the complexity and intensity of their work. At the same time, CMS is layering financial and utilization pressure across spinal fusion episodes under the Transforming Episode Accountability Model, selected spine services under the Wasteful and Inappropriate Service Reduction Model and individual physicians treating low-back pain under the Ambulatory Specialty Model.
None of those changes alone are likely to destabilize spine care. But together, they could create a system that becomes steadily better at performing surgery but less capable of getting the right patient to the right clinician at the right time.
The shortage will become an access problem
A Journal of Neurosurgery workforce study published in December projected the number of full-time-equivalent neurosurgeons would increase just 2.4% between 2022 and 2037, from 7,060 to 7,230.
Demand is expected to grow much faster. Under the researchers’ status quo scenario, the number of neurosurgeons needed would increase 18% to 8,310 by 2037, reducing national workforce adequacy to 87%. Under a scenario in which barriers to care are reduced for underserved populations, demand would reach 11,830 neurosurgeons and workforce adequacy would fall to 61%.
The researchers also found that metropolitan areas would remain better staffed than nonmetropolitan areas and projected wide state-level differences in workforce adequacy. That imbalance is already visible to physicians.
Vijay Yanamadala, MD, a spinal neurosurgeon with Hartford (Conn.) HealthCare, told Becker’s in May elective spine surgery waits would likely lengthen most sharply in midsize and rural markets.
“Patients already travel two to three hours for consultation in some regions,” he said.
As surgical expertise becomes concentrated in regional centers, some patients may benefit from higher-volume programs and more specialized teams. But centralization also requires transportation, time away from work and the ability to navigate referrals across health systems. Patients without those resources will experience the shortage differently from those who can travel.
The pipeline cannot be repaired quickly. Training a spine surgeon requires medical school, residency and often fellowship, making today’s recruitment and retention decisions consequential years into the future.
Amit Jain, MD, a spine surgeon and vice president of care transformation at Baltimore-based Johns Hopkins Medicine, told Becker’s that groups must invest earlier in mentorship, modernize training and create more sustainable practice structures.
“We must treat recruitment and retention as a continuous investment in a surgeon’s professional longevity,” he said.
The economics are moving in the opposite direction
In most markets, limited supply and rising demand increase the value of the service being provided. Spine care is not following that pattern.
“In every other industry, when supply goes down and demand goes up, prices rise,” Alexander Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, told Becker’s. “In medicine, the exact opposite happens.”
CMS’ 2026 Medicare Physician Fee Schedule finalized a 2.5% efficiency adjustment for many non-time-based services. The agency said the policy reflects productivity gains that may occur as services become more efficient over time. Spine surgeons have challenged the assumption that advances such as minimally invasive techniques necessarily reduce the intensity, complexity or responsibility involved in surgery.
Morgan Lorio, MD, former president of the International Society for the Advancement of Spine Surgery, called the policy a “silent erosion of value,” arguing that it does not adequately account for patient acuity, intraoperative decision-making or postoperative responsibility.
The financial reprieve contained in the 2026 conversion factor may also be temporary. In its proposed 2027 physician payment rule, CMS said the expiration of a one-year 2.5% statutory increase would contribute to a proposed 1.68% conversion-factor reduction for clinicians outside qualifying alternative payment models. Qualifying participants would face a proposed 1.19% decrease.
Those headline reductions do not capture every code-level change or the effect of CMS’ proposed practice-expense revisions. Actual outcomes would depend on each practice’s case mix, site of service, payer mix and participation in alternative payment models.
But the direction is difficult to miss: Spine practices would be asked to absorb more accountability while the underlying value assigned to physician work remains under pressure.
When complexity becomes a financial liability
Declining reimbursement does not affect every spine case equally. Routine operations with predictable resource use are easier to standardize, while revisions, deformity corrections and medically complex patients require more operating-room time, specialized staff, implants, monitoring and postoperative support.
Brian McHugh, MD, of McHugh Neurosurgery in West Islip, N.Y., told Becker’s that when payment does not reflect the resources required for high-acuity cases, independent practices can struggle to maintain those services. Dr.
Dr. Yanamadala described a related distortion: It takes time to explain why a patient does not need a procedure and coordinate conservative treatment, but Medicare often pays more reliably for performing a procedure than for a cautious approach.
“Most surgeons I know want to do the former; the system rewards the latter,” he said. The same tension is following spine care into outpatient settings. Under CMS’ proposed 2027 outpatient and ASC rule, the agency would remove 637 procedures from the inpatient-only list and add 618 codes to the ASC covered-procedures list. It also proposed a 2.4% average payment update for qualifying ASCs.
Yet proposed payments would decline for four high-volume pain procedures, including lumbar epidural steroid injections, facet injections and radiofrequency ablation.
Todd Albert, MD, surgeon-in-chief emeritus at New York City-based Hospital for Special Surgery, described the broader challenge to Becker’s as a “structural mismatch between reimbursement and inflation in surgical practice costs.”
Outpatient migration can lower costs and improve the patient experience, but eligibility alone does not create the staff, anesthesia coverage, technology, transfer protocols or postoperative resources required to operate a safe program. If reimbursement fails to support that infrastructure, centers with sufficient capital may continue expanding while smaller programs retreat from marginally reimbursed services and medically complex patients.
Medicare is injecting risk into every level of spine care
Spine care is becoming a test case for Medicare’s expanding use of mandatory accountability. TEAM, which launched Jan. 1, holds selected hospitals responsible for the cost and quality of spinal fusion episodes through 30 days after discharge. The WISeR model, also launched in 2026, uses prior authorization or prepayment review for selected services in six states. CMS says participating companies combine AI, machine learning and human clinical review to evaluate claims.
Beginning Jan. 1, 2027, the Ambulatory Specialty Model will evaluate selected orthopedic surgeons, neurosurgeons, pain specialists, anesthesiologists and physiatrists treating Medicare patients with low-back pain. The physician’s performance adjustment will attach to the individual clinician rather than remaining solely with a hospital or accountable care organization. Together, the models distribute accountability across hospitals, individual physicians and specific services. The risk emerges when responsibility and control are separated.
A surgeon may be evaluated on an episode involving imaging, therapy, pain management and hospital care provided by organizations the surgeon does not own. A hospital may be measured against a fusion target without controlling the patient’s underlying complexity or post-discharge environment. A necessary service may be delayed because the documentation satisfies clinical judgment but not the wording required by a reviewer.
Edward DelSole, MD, an orthopedic spine surgeon at Keystone Spine & Pain Management Center in Wyomissing, Pa., told Becker’s that standardized targets may work better for routine single-level procedures than for multilevel revisions and reconstructions. “The pressure isn’t on whether fusions get done; it’s on whether the hard fusions get done at the hospitals best equipped to do them,” he said.
If risk adjustment does not adequately reflect patient complexity, organizations gain a financial reason to favor predictable cases. The result may not be an explicit refusal; it could appear as narrower indications, additional reviews, longer scheduling delays or repeated referrals to another center.
The result could be a 2-tier spine care system
Prior authorization is already shaping who can access care. Kasra Ahmadinia, MD, director of minimally invasive spine surgery at Advanced Orthopedics of Oklahoma in Tulsa, told Becker’s that authorization should be eliminated or radically streamlined for evidence-based spine services. “Insurance-driven delays harm patients with neurological conditions and waste hours of a surgeon’s week on paperwork instead of care,” he said.
CMS says WISeR is intended to accelerate reviews and reduce burden, but physicians warn that standardized processes can miss neurological decline, unusual anatomy and failed conservative treatment. Patients backed by well-staffed practices may navigate repeated denials; others may abandon care or return with worsening conditions.
The result could be a two-tier system: integrated centers with the staff, data and capital to absorb payment volatility, and communities with limited access, fragmented care and fewer organizations willing to accept complex patients.
Better coordination and accountability could improve spine care. But lower payment, expanding prior authorization and greater physician risk will eventually surface in longer waits, narrower networks and fewer complex-care programs.
Spine surgeons agree that the greatest threat to the industry is not that technology stops advancing, it is that as patients’ care becomes more complicated, they might not have the means to access it.
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