As we approach the 2026 Annual Meeting, I wanted to scour some spine-related topics published in nonspine journals to get a sense of any common themes. Four studies published this year in JAMA journals are worthy of attention: a Military Health System comparison of low-value arthroscopic surgery under salaried versus fee-for-service pay (Schoenfeld et al, JAMA Network Open), an evaluation of bundled payments for outpatient spine decompression (Kilaru et al, JAMA Health Forum), a claims analysis of surgical costs under Medicare Advantage versus traditional Medicare (Politzer et al, JAMA Health Forum), and a secondary analysis of surgeons' fusion recommendations alongside a randomized spondylolisthesis trial (Seip et al, JAMA Network Open).

Concerningly, when read together, they somewhat challenge the assumption that health care decisions should be left up to the patient and their doctor. This kind of data should encourage NASS and all spine specialists to update, coordinate, and publicize an evidence base of outcomes that matter most to patients.

Schoenfeld and colleagues found that surgeons in salaried, direct-care environments had 41% lower adjusted odds of performing low-value arthroscopic surgeries (acromioplasty, meniscectomy, rotator cuff repair, and wrist and ankle arthroscopy) than fee-for-service colleagues treating the same indications, a gap that persisted even as low-value surgery declined in both groups over the study period. The results support the well-known theory that payment models do affect treatment recommendations.

Two other studies challenge surgeon decision-making with larger system levers. Kilaru and colleagues examined the first year of Medicare’s Bundled Payments for Care Improvement Advanced program and found that hospitals participating for outpatient spine decompression achieved roughly 9% lower episode spending and 2.2 fewer percentage points of 90-day readmission, with no change in mortality. The same mechanism, applied to inpatient fusion episodes at the same hospitals, produced no significant change in spending or quality, echoing earlier research that lumbar fusion is more resistant than decompression to cost reduction under bundling; probably due to more cost and decision variability with fusions (approach, implants, number of levels, etc.).

Politzer and colleagues analyzed 1.18 million Medicare surgical episodes and found spinal operations had one of the largest utilization reductions of any category in Medicare Advantage versus traditional Medicare: 13% lower, trailing only knee and shoulder arthroplasty, with no measurable 30-day mortality difference, an effect attributed largely to prior authorization and network steering rather than patient risk. Taken together, these two studies imply that cost savings is possible when discretion is taken away from the individual surgeon. The findings do not account for the possibility that, based on a surgeon’s read of the specific patient, a more aggressive index procedure may be able to spare a second operation later or if altering a surgeon’s recommendations negatively affect patient reported outcomes (PROs).

Seip and colleagues tested that possibility with a spondylolisthesis cohort, and their results are only partially reassuring. Alongside the Norwegian NORDSTEN-DS trial, surgeons at 16 departments recorded, before randomization, whether they would have recommended decompression alone or with fusion for each patient with degenerative spondylolisthesis and spinal stenosis. Patients were then randomized regardless of that preference. At two years, 75% of patients who received the surgery their surgeon would have chosen met the primary functional outcome, versus 73% who received the opposite. A difference whose confidence interval crossed zero widely and held across pain, function, and quality-of-life measures. Surgeons’ preferences tracked well with objective findings (eg, higher-grade spondylolisthesis and/or greater dynamic instability) but not with who benefited on PRO measures.

Reoperation rates told a different story: 14% of patients who received the option their surgeon did not prefer underwent a second operation at the index or an adjacent level within two years, versus 6% of those whose surgeon’s recommendation was followed, a gap that fell just short of statistical significance (95% CI, −0.2 to 16.1 percentage points). In other words, this study showed that surgeon judgement about decompression with fusion versus decompression alone did not predict two-year pain, function, or quality of life outcomes; but removing discretion doubled the risk of needing a reoperation.

The first three studies reviewed here (Schoenfeld, Kilaru, and Politzer) have some common limitations. All three rely on claims-derived proxies, readmission, emergency visits, and short-term mortality, measured over windows of 30 to 90 days, because that is what administrative data captures and how these programs are scored. For elective procedures on non-life-threatening conditions, those windows are too short to capture the outcomes that often matter most to patients: long-term pain, function, quality of life, and reoperation rates.

Until utilization studies are paired with multiyear PRO measures like these, it will be hard to get widespread support for more restrictive insurance networks or bundles. I anticipate more mandated PRO tracking for spine in the future, like what is currently required for joint replacement bundles.

Taken together, these four papers show that the case for exempting surgical decisions from external scrutiny may be weaker than we’d like. Shoenfeld showed us the reality that financial incentives measurably shape surgical thresholds. The insurance-based studies prove the importance of registering long-term clinical outcomes for spine surgical patients (and ideally with a comparison to nonsurgical patients) including pain, function, quality of life, and reoperation over years, to be collected and analyzed in addition to the administrative data on short-term mortality, readmission, and cost. I’d also be interested in seeing future research looking at how insurance interference in shared decision-making affects patient confidence, therapeutic alliance, and outcomes.

I hope this information is energizing to the spine community toward collaborative effort, and I think participating in the NASS Annual Meeting is an ideal place to develop creative solutions and organize efforts to best support our field and our patients. This issue of SpineLine is full of information highlighting collaborative work, innovation, and personal contributions of many old and new NASS members. It’s worth a careful read from cover-to-cover, especially the article on NASS strategy by outgoing President Bill Mitchell, a nicely written Invited Review on social determinants of health influencing spine surgical outcomes, 20 Under 40 winner profiles, and columns honoring the immense contributions of recently passed former NASS President Michael Heggeness, as well as Gunnar Andersson and Ralph Rashbaum. Please also see the comprehensive, multidisciplinary 2026 NASS Position Statement on Education, Training, and Competency for Spine Interventions. This is all in addition to the high-yield research summaries, coding tips, and NASS news you’ve come to expect. I hope to see many of you in San Antonio.

This is all in addition to the high-yield research summaries, coding tips, and NASS news you’ve come to expect. I hope to see many of you in San Antonio.