Spine surgery is advancing quickly, but many of the pressures making surgeons uneasy have little to do with what happens in the operating room.
Across recent Becker’s conversations, surgeons have pointed to reimbursement pressure, increasingly complex prior authorization, shrinking access to difficult cases, loss of autonomy and questions about whether the industry’s technology investments are delivering enough value.
Here are the issues drawing concern.
Reimbursement is changing what remains sustainable
Declining reimbursement continues to shape decisions about where surgeons practice, which procedures they offer and whether participating with insurers still makes financial sense.
CMS’ proposed 2027 Medicare Physician Fee Schedule would lower the conversion factor 1.68% for clinicians who are not qualifying advanced alternative payment model participants. CMS’ specialty-level analysis also estimates orthopedic surgery payments would decline 7% from proposed RVU and coding changes, while neurosurgery would see an estimated 2% decline.
The pressure is already influencing practice models. In July, three spine surgeons told Becker’s why they had considered or pursued out-of-network and cash-pay models as costs climbed and insurer payments tightened.
Peter Derman, MD, an endoscopic and minimally invasive spine surgeon in Dallas, said rising expenses and declining payments eventually reach a point where certain procedures are no longer economically viable.
Prior authorization is becoming an algorithm problem
Prior authorization has long frustrated spine surgeons, but physicians say the process is becoming more granular and increasingly shaped by insurer algorithms.
Bryce Basques, MD, director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., told Becker’s that algorithmic, AI-based prior authorization now requires surgeons to document cases using language that satisfies insurer-specific criteria.
Issada Thongtrangan, MD, an endoscopic and minimally invasive spine surgeon at MicroSpine in Scottsdale, Ariz., said many initially denied cases are eventually approved after appeals or peer-to-peer reviews.
“So we’re not really filtering out bad surgery, we’re just delaying good surgery,” Dr. Thongtrangan said.
The concern is not only administrative time. Surgeons have warned that delays can keep patients waiting for imaging, procedures and operations even when the clinical indication is clear.
Access to the hardest spine cases could narrow
Some surgeons are increasingly concerned about who will take on complex revisions, deformity cases and multilevel fusions as workforce and financial pressures mount.
Steven Cyr, MD, chief medical officer of Houston-based Surgical Associates in Spine, told Becker’s that surgeons willing to tackle the most complex cases are increasingly concentrated at major academic centers.
“I think the number of those is getting smaller and smaller,” Dr. Cyr said.
That could have the greatest effect on patients outside major metropolitan markets. Recent workforce projections and surgeon interviews have raised concerns about longer waits, geographic disparities and fewer organizations willing to absorb the financial risk of complex care.
Surgeon autonomy is getting harder to preserve
Consolidation is creating another question for spine and orthopedic surgeons: not simply who owns the practice, but who controls clinical and operational decisions.
Health systems and private equity-backed groups can provide capital, administrative support and stability, but surgeons have raised concerns about what happens to decision-making around staffing, scheduling, technology, site of service and patient care after a practice joins a larger organization.
“Ownership matters less than governance,” Cory Calendine, MD, an orthopedic surgeon at Bone and Joint Institute of Tennessee in Franklin, told Becker’s.
Other surgeons said clinical independence can come under pressure in either model, whether through centralized health system governance or financial and productivity expectations within private equity-backed organizations.
Technology is advancing faster than the proof of value
Robotics, navigation, AI and new implants continue to expand what spine surgeons can do, but the cost and pace of innovation are also creating uncertainty.
Nine surgeons recently told Becker’s that purchasing a robot alone is not enough to create value. Consistent surgeon utilization, case volume, trained teams and redesigned workflows are often necessary to justify the investment.
“The robot itself doesn’t create value, how you use it does,” Dr. Thongtrangan said.
Questions extend beyond financial ROI. Some surgeons said it remains unclear whether robotics consistently translates into fewer revisions, better outcomes or meaningful efficiency gains compared with established alternatives.
The broader innovation question is similar. Tan Chen, MD, an orthopedic spine surgeon at Inova Health in Falls Church, Va., told Becker’s that the specialty now has more approaches, implants and motion-preserving options, but not necessarily more agreement about which ones are best.
“Nobody truly knows what is best,” Dr. Chen said.
Burnout is becoming a longevity issue
The physical and psychological demands of spine surgery remain another concern, particularly as administrative work and productivity expectations grow alongside clinical complexity.
Safdar Khan, MD, a professor of orthopedic surgery at the University of California Davis, and Todd Albert, MD, surgeon-in-chief emeritus at Hospital for Special Surgery in New York City, have pointed to the emotional toll adverse events can take on surgeons. They described how guilt, anxiety and self-doubt after complications can persist and influence future clinical decisions, with implications for both physician well-being and patient safety.
Burnout can also stem from the systems surrounding physicians. Vijay Yanamadala, MD, a neurosurgeon and spine specialist with the Ayer Neuroscience Institute at Hartford (Conn.) HealthCare, said practices need to structure technology and teams in ways that allow clinicians to remain focused on patient care.
“Burnout happens when systems make that feel impossible,” Dr. Yanamadala said.
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.
