While all physician specialists must undergo years of grueling training, long work hours and high-stress work days, some are favored more by Medicare payment systems than others.
A number of factors, including specialty and workplace, can determine how physicians are compensated.
As Medicare continues to cut reimbursement rates, the cost of practicing continues to increase year-over-year, creating difficulties, especially for small, physician-owned practices without the economic backing of a major system.
Three spine specialists, Anthony DiGiorgio, DO, Praveen Mummaneni, MD, and Luis Tumialan, MD, spoke with Becker’s about why it is becoming harder for small, physician-owned health systems to get paid and why the current payment system favors large hospitals.
Note: This is a joint response, co-authored by Dr. DiGiorgio, Dr. Tumialan and Dr. Mummaneni.
Dr. DiGiorgio, Dr. Tumialan and Dr. Mummaneni: Becoming a spine surgeon requires lengthy and grueling training. After medical school, a spine surgeon must complete either a neurosurgical or orthopedic surgery residency, both of which are time-consuming and physically and mentally taxing. Typically, spine surgeons then pursue post-residency fellowship training for a total of 6-8 years of postgraduate training at relatively low wages. The night and weekend calls during this training are unpredictable due to emergency, middle-of-the-night, life- and limb-saving operations. At the end of training, spine surgeons are not done with exams. They participate in lifelong learning and go through the rigorous process of board certification. They spend countless hours studying well into their third decade of life for an oral exam and then recertify every ten years thereafter.
Once in practice, spine surgeons spend hours in the operating room performing technically complex and often high-risk procedures and taking trauma calls. Spine trauma call involves waking in the urgent surgeries on nights, weekends and holidays that can mean the difference between a patient’s paralysis and recovery. Since the surgeries are high-risk, there is often malpractice litigation, which the surgeon has to contend with.
Those who choose this profession love the field and love taking care of patients. In return for this rigorous preparation and service, it is reasonable for spine surgeons to receive financial compensation. However, Medicare has cut physician reimbursement, added layers of compliance requirements over a period of two decades. We are now in an economic environment that favors large hospital systems and financially punishes independent practices with high regulatory burdens. Adjusted for inflation, Medicare reimbursement for physicians has declined by nearly 50 percent since 2000. In contrast, the costs of running a medical practice have steadily increased. Rent, utilities, staff wages and medical equipment have all gone up, while reimbursement has not kept up with inflation and is thus decreased.
Physicians are the only category of government contractors who are routinely asked to take a pay cut. Meanwhile, hospital systems and managed care organizations have seen payment increases that track with or exceed inflation. Despite this, our patients often overestimate how much we are compensated. On average, patients guess that Medicare reimburses us nearly six times more than it actually does.
This payment erosion has especially harmed independent spine practices. Unlike hospitals, independent practices do not have access to revenue streams such as facility fees, imaging, therapy services, or the 340B drug discount program. Worse still, current law restricts physicians from owning hospitals, cutting them off entirely from some of the infrastructure that could sustain independent care. Section 6001 of the Affordable Care Act essentially froze physician-owned hospitals in place, limiting their ability to expand or serve more patients, regardless of quality or efficiency or cost containment.
On top of this financial pressure, physicians face growing regulatory burdens. Medicare’s quality metric programs, though well-intentioned, imposed significant costs on practices and offered little evidence of improved outcomes. These programs often require extensive documentation and administrative data reporting, diverting time away from patient care. Now, with the introduction of bundled payment models like TEAM, spine surgeons face even more restrictions and complexity, with no guarantee of better results for patients.
All of this has created an environment that is increasingly hostile to independent practice. When spine surgeons choose to retire early, sell their practices, or opt out of Medicare, it is not due to a lack of commitment to patients. It is because the system has made it nearly impossible to continue providing care in a sustainable way.
Declining reimbursement in spine surgery is well documented. As Medicare decreases reimbursement, physicians feel that their skills are a depreciating asset. This messaging contributes to burnout, a real problem among physicians. Spine surgeons have much higher rates of burnout than the general US population.
Spine surgeons are asking for fairness. Fairness translates to reimbursement that keeps pace with inflation. Fairness includes being allowed to own and operate the facilities where surgeons can deliver care efficiently and at a lower cost. Fairness includes reducing regulatory burdens that interfere with spine surgeons’ ability to focus on patients rather than on administrative data reports. Above all, fairness means being recognized and supported as the highly trained professionals our patients depend on.
The current trajectory is not sustainable. If we want to preserve access to high-quality spine care in the United States (including in rural and underserved population areas), we must fix the economic and regulatory structures that are driving spine surgeons out of practice. Otherwise, we risk a future where fewer patients have access to the kind of timely, expert care that spine surgeons are trained to deliver.