CMS physician fee rates are a top concern for physicians, and spine surgeons see additional opportunities in changing policies specific to their specialty.
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.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, April 22.
Editor’s note: Responses were lightly edited for clarity and length.
Question: What changes would you like to see in CMS policies affecting spine procedures? Why?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: CMS should increase reimbursement for spine procedures. These operations are technically difficult and involve a lot of postoperative, unreimbursed care. If Medicare and CMS wants to maintain access, they have to face the hard truth that just because patients “take Medicare” does not mean it will always be that way, nor that there is no problem. Medicare reimbursements have been going down for 20+ years. Medicare Advantage plans bilk the public out of their tax dollars and in return these plans get more money from the government to fund their ill gotten gains and not provide coverage for care. If Congress chooses to continue this route, single payer is around the corner with the next administration. You want to develop and maintain competition? Stop giving out corporate welfare checks and get patients the care they are paying for.
Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): Let’s take a look at one of the unique changes about to take effect on Jan 1, 2026: TEAM (Transforming Episode Accountability Model). This is a mandatory bundled payment program running from January 2026 to December 2030, focused on five high-cost surgical procedures — including spinal fusion. Under this model, CMS sets a target price for a 30-day episode of care, and hospitals continue billing fee-for-service. However, if total Medicare spending for the episode falls below the target price (and meets quality benchmarks), the hospital may receive a bonus payment; if spending exceeds the target, the hospital may owe a repayment to CMS.
How will costs be measured?
How will quality be assessed?
How are they handling risk adjustment?
Not all fusions are created equal.
So what changes would I like to see?
1. CMS should build models that reward true value, not just low cost (or else this is just a race to the bottom).
2. They should incorporate outcome measures that matter; not just readmissions and “complications”
3. They should engage more clinicians in shaping definitions of quality and appropriateness.
4. CMS should empower systems to collect data, measure outcomes, and improve their own care delivery — rather than just guessing at what CMS wants (because we still are not quite sure how CMS develops their metrics).
Pierce Nunley, MD. Spine Institute of Louisiana (Shreveport): I would propose revising regulations to permit multi-level anterior cervical discectomy and fusion and anterior lumbar interbody fusion procedures in ASCs. Two- and three-level ACDFs are routinely and safely performed on an outpatient basis in hospital settings. For appropriately selected patients, equitable reimbursement policies should allow these procedures in ASCs, which often provide a cleaner and safer environment compared to many hospitals. This shift would also reduce healthcare costs, creating a mutually beneficial outcome for patients, providers and payers.
Although anterior-approach ALIFs generally warrant a hospital setting, the same procedural code encompasses lateral fusions, which are notably safer and less complex, carrying fewer risks. However, CMS designates the ALIF code as inpatient-only, precluding reimbursement for ASCs despite the safety of performing most single-level and many two-level cases in such settings. Allowing these procedures in ASCs would lower costs and enhance patient care, benefiting all stakeholders — except, perhaps, hospital associations
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Medicare reimbursement to physicians is controlled at the federal level and markedly affected by the winds of political dynamism. A recent article in JNS outlined the adjustments for inflation and the average reimbursement for all spinal surgical procedures had decreased by 33.8% from 2000 to 2021. Healthcare costs continue to rise, so changes are necessary to ensure the financial status/success of spine surgery. There have been several strategies and alternative models of physician reimbursement that have been proposed. Especially for those complex spinal surgeons whose proclivity/dominance for mostly Medicare/Medicaid patients is manifest. These models such as the implemented Quality Payment Program, passed as part of MACRA and Bundled Payment Programs, would be tied to the implementation of high-value care and contingent on increasing favorable patient outcomes while decreasing the overall costs of patient care.
