For a generation, the hardest question in spine surgery was whether a case could be done at all, and then whether it could be done outside a hospital. Surgeons answered it. Fusions and decompressions once confined to inpatient suites now happen routinely in ASCs, at lower cost, with high patient satisfaction and outcomes that hold up. On the clinical merits, the argument is essentially over.
The argument that has replaced it is quieter, and it has almost nothing to do with the operating room. It is about whether a practice’s data systems can prove what its surgeons already know how to do. As Medicare forces spine into mandatory bundled payment and threads AI through prior authorization, the binding constraint on a program’s success is shifting from skill to infrastructure.
Ask enough spine leaders and the same word surfaces: the bottleneck is not expertise. It is plumbing.
The deadline that made it real
The reckoning arrived with a date. On Jan. 1, 2026, spinal fusion entered a mandatory Medicare bundle for the first time. Under the Transforming Episode Accountability Model, CMS makes selected hospitals answerable for the cost and quality of a fusion episode from the first incision through 30 days past discharge, measured against a regional target price, with the model running through 2030.
A bundle rewards the organization that can show a clean, coordinated, complication-free episode and penalizes the one that cannot, no matter how flawless the surgery. That is a documentation problem wearing a clinical disguise. And it did not arrive alone.
The same month, CMS bolted prior authorization onto traditional Medicare through its Wasteful and Inappropriate Service Reduction model, enlisting AI and machine-learning vendors to screen 17 targeted services. The target list reads like a page torn from a spine surgeon’s schedule: cervical fusion, epidural steroid injections, image-guided lumbar decompression, vertebral augmentation. Approval, denial and the paper trail to contest a denial now move through data pipelines rather than phone calls. The surgeon who cannot produce the record on demand loses the argument before it starts.
The money follows the building. The data follows the money.
Underneath the policy sits a number surgeons cannot unsee. For 2026, Medicare’s ASC conversion factor is $56.322, against $91.415 in the hospital outpatient setting, which means the identical procedure has long paid one rate or another based on the address where it was performed. Site-neutral proposals aim to collapse that gap. If they do, the migration to ASCs accelerates, and with it the pressure on outpatient programs to prove their results in a currency payers accept.
When the infrastructure is there, the model delivers. The first year of a bundled-payment program for outpatient spine surgery was associated with $1,201 in lower total episode spending and 2.2% fewer return inpatient admissions than at non-participating hospitals. But savings like that are invisible, and therefore unbankable, to any organization that cannot measure them in the first place.
What actually keeps surgeons up at night
Put the question to spine surgeons and they seldom name the operation. William Kemp, MD, a spine surgeon in Richmond, Va., reduced it to a sentence: “The biggest challenge today isn’t really surgery, it’s the environment around the surgery.” The friction he described is increasingly automated, with payers leaning on AI to interrogate physical therapy notes and imaging reads.
The measurement problem runs deeper than friction; it is structural. Aqib Zehri, MD, a neurosurgeon at The Oregon Clinic in Portland, Ore., went further, arguing that “bundled payments don’t really exist in spine surgery as of right now.” His reason is variability.
A single-level decompression, a revision and a complex deformity correction are not variations on one episode; they are different operations on different patients with different ages, body-mass indexes and risk profiles. A crude bundle pays out on the easy cases and quietly punishes the surgeon willing to take the sickest ones, which is exactly the work no one else can do.
That is the case for infrastructure, made in reverse. Vijay Yanamadala, MD, a spinal neurosurgeon at Hartford (Conn.) HealthCare has argued that the answer is risk stratification fine-grained enough to capture what truly drives spine outcomes: social determinants, psychological comorbidity, prior surgical history and whether the indication to operate was sound to begin with.
None of that can be captured, weighted or reported by a system not built to do it. The clinical judgment is real. The apparatus to prove it is what is missing.
Where it all has to converge
The data a bundle demands does not sit in one place. It is scattered across the surgical record, the imaging archive, the therapy notes and the payer’s authorization file, four systems that rarely speak the same language. Pulling them into a single coherent account of an episode is where value-based contracts are won or lost, and the electronic health record is the junction where that either happens or fails.
Christian Zimmerman, MD, of Boise, Idaho-based St. Alphonsus Medical Group and SAHS Neuroscience Institute, has described how cost and outcome comparisons only become useful when matched across an entire system through a shared EHR and a common cost-reporting structure. Absent that backbone, benchmarking against peers is little more than educated guessing.
Across organizational lines, the difficulty compounds. Debi Brobst, CIO of Toledo, Ohio-based ProMedica, told Becker’s “healthcare interoperability is driven by data, which drives patient care,” and pointed to standardized Fast Healthcare Interoperability Resources interfaces and federal frameworks like the Trusted Exchange Framework and Common Agreement as the machinery slowly enabling exchange at national scale. For a spine program on the hook for a 30-day episode spanning surgery, skilled nursing and follow-up, moving a record cleanly across those handoffs is not a convenience. It is the line between documenting the episode and eating the loss.
The inversion spine leaders have not fully priced in
All of this reorders the usual logic of where to spend. Robotics, navigation and new implants draw the capital and the headlines; CMS granted a New Technology Add-On Payment worth up to $21,125 for cases using Carlsmed’s aprevo cervical implant. But the barriers surgeons actually describe are not on the instrument tray. They live in measurement, documentation and the ability to move information from one system to the next.
The surgeons who have already built for this speak about timing with a certain urgency. At Charlotte, N.C.-based OrthoCarolina, hip and knee surgeon Brian Curtin, MD, spent 14 years constructing a bundled-payment program and now says he earns more on a joint inside a bundle than he ever did on fee-for-service, with volume rising from roughly 80 bundled patients in the first year toward more than 2,000 in 2026. That is not a clinical achievement. It is an infrastructure one.
The outpatient migration is accelerating. Mandatory risk is here. The voluntary era, the one that let a practice postpone the data question, is closing.
Which programs come out ahead will turn less and less on what their surgeons can do once the patient is asleep, a matter no longer in any real doubt, and more and more on whether the systems around them can prove it once the patient goes home. The groups doing that unglamorous work now will write their own contracts. The ones still waiting will sign whatever they are handed.
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.
