Spine surgeons head into 2027 facing what the North American Spine Society calls a “three-headed” financial squeeze, after CMS finalized physician and outpatient payment rules that left most of the specialty’s objections unaddressed.
The final physician fee schedule cuts the conversion factor 2.31% for most clinicians, deeper than the 1.68% cut CMS proposed, and trims payment for same-day visits. The rules land weeks before a mandatory CMS model begins holding selected spine providers accountable for low back pain care on Jan. 1.
Paul Saiz, MD, an orthopedic surgeon at 3 Crosses Spine in Las Cruces, N.M., and NASS’ health policy director, shared the society’s response with Becker’s.
Three cuts, compounding
NASS sees the conversion factor cut, practice expense restructuring and the modifier 25 payment reduction as one combined blow rather than three separate adjustments.
“The combination of the conversion factor cut, practice expense restructuring, and modifier 25 payment reduction will cause significant systemic pressures on physicians and will likely lead to long-term consequences,” Dr. Saiz said.
The society expects those pressures to erode independent practices and speed consolidation into hospital-based health systems. NASS also warned that care and access could suffer as practices adapt, whether by splitting evaluation and management visits from procedures or by opting out of Medicare altogether.
More spine cases in ASCs — and harder choices about which ones
The final outpatient rule adds 619 procedures to the ASC covered procedures list. CMS projects ASC payments for musculoskeletal and nervous system procedures will rise 6%, while some common spine pain procedures, including lumbar transforaminal epidural steroid injections, will decline.
With the site-of-service differential gone and inpatient-only codes phasing out, Dr. Saiz said ASCs will take on more spine procedures. That growth forces triage. Larger cases moving over from hospitals will consume ASC resources and could displace smaller pain procedures centers now perform, and some of those, such as transforaminal epidural steroid injections, may make more sense in the office.
“Ultimately, the setting for spine surgery should be determined by the needs of the patient, not by a blanket preference for a hospital or an ASC,” he said.
For selected patients, an ASC can offer a focused outpatient experience and recovery at home. But Dr. Saiz said convenience and lower costs should not override clinical judgment, and outpatient surgery is not appropriate for every patient or every spine procedure. Setting decisions should weigh procedure complexity, the patient’s medical conditions, anesthesia needs, expected recovery and support at home.
NASS outlined baseline safeguards for ASC spine care: qualified surgical and anesthesia teams, suitable equipment, clear discharge criteria, reliable follow-up and a defined plan for hospital transfer. Hospitals remain essential for complex surgery and patients who need inpatient monitoring.
“The shift to ASCs should complement, not replace, the role of hospitals in comprehensive spine care,” Dr. Saiz said.
Patients should also understand why a setting is recommended, their alternatives, expected out-of-pocket costs and whom to call during recovery.
“The guiding principle is straightforward: the right procedure, for the right patient, in the right setting, with the right safeguards,” he said.
A year of accountability for a single episode
The Ambulatory Surgery Model, launching Jan. 1, 2027, will hold selected spine providers accountable for both the cost and quality of their patients’ care. The cohort spans orthopedic surgery, neurosurgery, pain management, physical medicine and rehabilitation, interventional pain management and anesthesiology — a structure NASS said puts “a lot of cooks in the kitchen” and blurs clinical oversight across the care continuum.
The central flaw, Dr. Saiz said, is a mismatch in timing. “Surgeons typically interact with patients during discrete episodes, yet under this year-long framework, they are held accountable for clinical decisions made by other healthcare providers throughout the year,” he said.
Because each specialty treats patients with its own clinical nuances, NASS maintains that holding surgeons responsible for other practitioners’ management decisions is “fundamentally unfair.”
NASS acknowledged there is no clear formula for preparing for fee-for-service cuts on one side and value-based mandates on the other. The society has asked CMS to revise the model and exclude surgeons from the low back pain cohort.
“Without these critical policy adjustments, spine specialists face an escalating financial squeeze that threatens practice viability and patient access to care,” Dr. Saiz said.
One concession, and the next fight
During the comment period, NASS joined the American Association of Neurological Surgeons, , the Congress of Neurological Surgeons, the American Academy of Orthopaedic Surgeons and the International Society for the Advancement of Spine Surgery in opposing the proposed changes. Spine surgeons urged CMS to eliminate the indirect practice cost index, withdraw the 50% facility practice expense reduction, rescind efficiency adjustments on surgical spine codes, drop the modifier 25 cuts and exclude surgeons from the low back pain model.
CMS meaningfully addressed one of those requests, Dr. Saiz said. The final rule exempts procedures with 10- and 90-day global periods from the modifier 25 cut, though zero-day global procedures remain subject to it. The agency left the broader objections to fee reductions and model design unaddressed.
Practices are already adjusting. Many physicians report considering splitting procedures and E/M visits across separate days to preserve payment, and a growing number say they may opt out of Medicare, a move that would narrow beneficiaries’ access to specialized spine care.
NASS will now press both CMS and Congress. Its central ask: a transparent analysis and public release of cumulative impact data showing the combined financial toll of these cuts on spine providers. The society also plans to keep defending spine practices against financial collapse and forced absorption into hospital-based systems, with the aim of preserving patients’ direct access to spine care.
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.
