Thank you for the time. Three Medicare programs now touch almost every spine patient we see, and they started arriving this year. One of them, TEAM, puts this hospital at financial risk for every spinal fusion episode. One, WISeR, changes how traditional Medicare authorizes spine procedures in New Jersey. And one, ASM, starts measuring spine clinicians individually in 2027.

I have asked to be the physician lead for our service line on these programs. This talk is what I have learned, checked against CMS's own rules and participant files, and what I propose we do. Every fact on these slides links to the CMS document it came from.

Four numbers to frame the conversation.

Forty-four New Jersey hospitals are in TEAM, every one of them in the New York-Newark-Jersey City metropolitan area, which includes every hospital in Bergen and Hudson CMS 2026. That includes us and every hospital we compete with.

Two percent: CMS discounts the spinal fusion target price by two percent below regional historical spending CFR 2026. To break even we have to beat our own region's history.

Three days: since January 15, traditional Medicare in New Jersey requires prior authorization or pre-payment review for epidural steroid injections, kyphoplasty and vertebroplasty, and one cervical fusion code, with a target decision time of three days CMS 2026.

And plus or minus nine to twelve percent: under ASM, a spine clinician's entire Medicare Part B income moves by up to that amount based on how their back-pain episodes score CFR 2026. As you will see, ASM's geography is narrower than people assume, and today it does not include Bergen or Hudson.

The landscape in one line. The older joint-replacement bundles have ended: CJR closed at the end of 2024 and the voluntary BPCI Advanced program at the end of 2025 CMS 2026 CMS 2026. TEAM replaced them in January 2026 as a mandatory hospital model with five episode types, one of which is spinal fusion CMS 2026. WISeR began the same month in six states, New Jersey among them CMS 2026. ASM's first performance year is 2027, with payment adjustments starting in 2029 CMS 2025. In 2028 CMS adds CJR-X, a national joint-replacement model that excludes TEAM hospitals and does not include spine CMS 2026. TEAM runs through 2030, WISeR through 2031, and ASM's last payment year is 2033.

The point for us: these are not pilots that will be gone next year. They span the next five to seven years of our service line.

If you remember one slide, make it this one.

TEAM puts the risk on the hospital. CMS sets a target price for a spinal fusion episode, the surgery plus thirty days, and the hospital is paid or pays back the difference between that target and actual Medicare spending, adjusted for quality CFR 2026. Surgeons carry no TEAM risk unless they sign a sharing arrangement with the hospital.

ASM puts the risk on the individual clinician: back-pain episode cost and quality, scored against peers, applied to all of that clinician's Medicare Part B payments CFR 2026.

WISeR puts the risk on whoever bills the service, the clinician and the facility, through denial if the documentation does not meet Medicare's coverage criteria CMS 2026.

The bottom of the slide is why one person can lead all three. The same levers move every one of them: the right patient, the right operation and the right setting; documented conservative care; outcome scores before and after; implant cost; length of stay; discharge home rather than to a facility; and no avoidable readmission. Those are clinical decisions, which is why this needs a surgeon in the room.

Follow one traditional Medicare patient with back and leg pain.

Clinic visit, imaging, therapy. If an epidural injection is ordered, WISeR requires prior authorization in New Jersey CMS 2026. If surgery is chosen, the gate depends on the operation: a kyphoplasty or the cervical fusion code 22554 goes through WISeR, while an ACDF in a hospital outpatient department goes through a separate national hospital outpatient prior authorization program.

Where ASM applies, the clinician is scored on the whole back-pain episode, which opens with an office visit or therapy claim and counts imaging, injections, therapy, medications, post-acute care and surgery within its window CMS 2023.

And when a fusion is done in the hospital, inpatient or outpatient, the hospital owns that episode for thirty days after discharge under TEAM: readmissions, a skilled nursing facility stay, an emergency visit, everything Medicare pays CMS 2025.

Three programs, three different owners, one patient. Our job as a service line is to make sure the hand-offs between them are deliberate.

TEAM first, because it is already live for this hospital and it is the one with direct financial consequence for us this year.

TEAM in one slide.

It is mandatory for acute care hospitals in the metropolitan areas CMS selected, from January 2026 through December 2030. The New York-Newark-Jersey City area is selected, so this hospital and every Bergen and Hudson competitor is in CMS 2026 CMS 2026.

Five episode types; spinal fusion is one. The triggers are the inpatient fusion DRGs, with three more DRGs, 523 to 525, added from October 2026 CMS 2026, and five hospital outpatient codes: 22551, the ACDF; 22554; and the three lumbar fusion codes 22612, 22630 and 22633.

The episode is the procedure plus thirty days after discharge, and almost all Medicare Part A and B spending in that window counts: the surgeon, anaesthesia, the hospital stay, readmissions, skilled nursing, home health, therapy, emergency visits CFR 2026. The hospital must include referral to primary care in discharge planning.

One correction to what is circulating: surgery centers are not in TEAM, and a fusion done in an ambulatory surgery center does not start a TEAM episode. CMS considered that and declined it in the 2025 rule CMS 2024. The only exception is a patient who is already inside an open TEAM episode for something else.

How the money works.

CMS sets a target price for each episode type from three years of regional spending, weighted toward the most recent year, adjusted for patient risk and trended forward CFR 2026. New Jersey is priced in the Middle Atlantic region. Then CMS takes a discount: two percent for spinal fusion.

At reconciliation, CMS compares actual thirty-day Medicare spending with the target. Below target, the hospital is paid the savings; above it, the hospital repays, within the limits of its track. Track 1 had no downside risk and was open to every hospital only in the first year; most hospitals are now in two-sided risk, and Track 3 caps gains and losses at twenty percent CMS 2025.

Quality adjusts the result through a composite score: hospital-wide readmission, patient safety and harm measures, failure to rescue, and from 2028 a patient-reported measure of how well information is transferred at discharge, which applies specifically to joint replacement and spinal fusion CFR 2026.

Two points that are often misunderstood. Target prices are set per DRG or outpatient code, so moving a case to the outpatient setting changes which target applies rather than creating a single site-neutral price. And implant cost does not change Medicare's episode spending, because Medicare pays the DRG regardless of the implant. Implant cost changes the hospital's margin, and documented internal savings are one of the two legal sources of gainsharing. That is why implants still belong on our agenda.

Where the thirty-day money goes, and therefore where we can act. This slide is our clinical judgement rather than CMS text, but each item maps to either episode spending or a TEAM quality measure.

Before surgery: the right indication and the right operation for the patient in front of us; optimisation of glucose, nicotine, nutrition and bone health; deciding the expected discharge destination at the time of booking, not on post-operative day two; and making sure the patient has a primary care physician, because the rule requires a primary care referral.

In the hospital: length of stay and early mobilisation; complications and harm events, which feed the safety measures; discharge home with services rather than to a facility wherever that is safe; and the primary care referral documented.

After discharge: readmissions and emergency visits are the largest avoidable costs in most surgical episodes, and post-acute facility stays are next. A call within forty-eight hours, a clinic that sees wound and pain problems the same day, and a two-week visit keep those patients out of the emergency department.

None of this is new medicine. What is new is that the hospital now carries the bill for every one of these, and the quality score measures several of them.

TEAM's financial risk is the hospital's, but the regulation lets the hospital share gains, and some losses, with the surgeons who drive the results. That is how we align.

Physicians and physician groups can be TEAM collaborators CFR 2026. The conditions are specific. The arrangement must be in writing, signed before the care is furnished, and voluntary. The hospital must select collaborators by written quality criteria, never by the volume or value of referrals, which keeps this inside the fraud and abuse rules. Payments can come only from the CMS reconciliation payment or from documented internal cost savings, such as implant pricing, and at most once a year. The surgeon must meet the hospital's quality criteria for the episode and must have cared for a TEAM patient that year. If the hospital owes CMS money, it can share that downside too, but no more than a quarter of the repayment with any one collaborator and half in total. And the arrangement may not reduce medically necessary care or restrict the choice of devices or treatment.

My proposal, which is on the final slides: we design a written collaborator arrangement for the spine service line with quality criteria that we choose together, so that the surgeons who do the work of lowering episode cost share in it.

Second, the prior authorization programs. These affect scheduling and revenue cycle this month, not in a future performance year.

Exactly which spine services need prior authorization in traditional Medicare in New Jersey, as of the current CMS guide CMS 2026.

WISeR covers epidural steroid injections, the interlaminar and transforaminal codes; kyphoplasty and vertebroplasty; one cervical fusion code, 22554; and the paddle-lead spinal cord stimulator, 63655.

Two common spine procedures are covered by a different program. An ACDF, 22551 and 22552, done in a hospital outpatient department, and a percutaneous stimulator, 63650, have needed prior authorization since 2021 under the national hospital outpatient prior authorization program, which the hospital submits CMS 2026. So the ACDF claim in some of what is circulating is right in effect but wrong in program.

And two things that are not in WISeR. Facet procedures were excluded in an April 2026 correction, and percutaneous image-guided lumbar decompression has been delayed indefinitely CMS 2026 CMS 2026.

All of this is traditional Medicare. Medicare Advantage plans run their own prior authorization and are not affected by WISeR.

How a request works. For a service on the list and a traditional Medicare patient, the request goes either to the New Jersey technology vendor, Genzeon, through its HIP One portal, or to Novitas, our Medicare contractor; one or the other, not both Novitas 2026. The documentation is judged against the existing Medicare coverage policies: for an epidural, four weeks of pain and failed noninvasive care with matching imaging; for cervical fusion, twelve weeks of multimodal care or a documented exception.

A decision comes in about three calendar days, two if expedited CMS 2026 CMS 2026; the model was announced in the Federal Register in 2025 CMS 2025. If affirmed, the tracking number goes on the claim and is valid for 120 days; in the surgery center and the hospital it is the facility claim that is reviewed, so the hospital's scheduling and revenue-cycle teams need that number. If not affirmed, we fix the gap and resubmit, and a peer-to-peer is available. And if no request is made, the claim goes to pre-payment review, with forty-five days to send records and payment on hold.

From July 2026 there is an exemption, the gold card: a clinician with at least ten requests and a high approval rate can be exempted, and the exempt clinician's identifier goes in the operating or ordering field on the facility claim. Getting our surgeons and pain physicians to gold-card status is a realistic first-year goal.

Third, ASM. It is the model with the largest stakes for individual clinicians, and the one most often described inaccurately.

ASM in one slide.

It is mandatory, finalized in the 2026 physician fee schedule rule. Performance years are 2027 through 2031, and because payment lags by two years, the payment adjustments run 2029 through 2033; some summaries say 2028, which is wrong CMS 2025 CMS 2025.

Two conditions: low back pain and heart failure. The low back pain cohort covers orthopaedic surgery, neurosurgery, physical medicine and rehabilitation, pain management, interventional pain and anaesthesiology; nurse practitioners and physician assistants are not included.

Clinicians are scored against their peers in the same cohort on four categories, built on the MIPS value pathway framework: quality, cost, improvement activities and promoting interoperability. Quality and cost are scored per clinician, the other two at the group level CMS 2026.

The adjustment applies to all of the clinician's Medicare Part B professional payments, not just back-pain care: plus or minus nine percent in 2029 and 2030, then ten, eleven and twelve CFR 2026. A surgeon's fusion and deformity income moves with their back-pain score.

Eligibility requires twenty or more low back pain episodes two years before the performance year and practice in a selected area. The final cohort is 3,319 clinicians in 46 states, and the participant portal opened in September 2026 CMS 2026 CMS 2026; CMS's model page and FAQ have the details CMS 2026 CMS 2026.

This is the most important correction to what is circulating. ASM is not New Jersey-wide.

CMS selected areas by stratified random sampling of metropolitan areas and metropolitan divisions CMS 2025. In New Jersey the selected areas are the Lakewood-New Brunswick division, which is Middlesex, Monmouth, Ocean and Somerset; Trenton-Princeton; Vineland; Warren County through the Allentown area; and Salem through the Wilmington area. There are 132 New Jersey low back pain clinicians in the cohort, 120 of them in Lakewood-New Brunswick CMS 2026. The often-quoted 22 OrthoNJ clinicians are real, and every one of them is assigned to Lakewood-New Brunswick.

Not selected: the New York-Jersey City-White Plains division, which is Bergen, Hudson and Passaic; the Newark division; Camden; and Atlantic City Census 2023.

So a clinician whose back-pain patients are mostly seen in Bergen or Hudson is not an ASM participant today. Two cautions. A clinician is assigned to the area where most of their episodes are seen, so a surgeon with a large clinic in Middlesex or Monmouth could be in. And each year from 2028, CMS adds newly eligible clinicians in the selected areas.

What ASM actually measures, from the MIPS low back pain cost measure and the ASM fact sheets.

An episode starts with an office visit, a therapy service or a manipulation coded for low back pain, confirmed by a second low back pain claim within sixty days, which can be an injection, imaging or another visit CMS 2023. Surgery is not a trigger, and no episode opens if spine surgery happens from ninety days before to sixty days after the trigger. The window is 120 days and each new qualifying claim extends it, up to 484 days. Everything Medicare pays in that window counts: surgery, hospital stays, injections, imaging, therapy, medications, post-acute care and equipment. The serious diagnoses, cauda equina, infection, osteoporotic fracture, myelopathy, trauma and tumour, are excluded.

The quality measures finalized for 2027 are a patient-reported functional status change, depression screening, BMI screening and high-risk medications in older adults CMS 2026. The 2027 proposed rule would swap the functional status measure for a functional outcome assessment that accepts the Oswestry or PROMIS, and add a claims measure of lumbar MRI use for low back pain CMS 2026; that rule is not final yet.

The practical message: the clinician who orders an early MRI, a series of injections and months of therapy before a decision is the clinician whose episode cost rises. The clinician who collects outcome scores and documents a deliberate pathway scores well.

ASM does not cover Bergen and Hudson clinicians today. Here is why I still want us to build for it.

First, our clinicians can be pulled in: a surgeon whose back-pain episodes are mostly seen in a selected area is assigned there, and each year from 2028 CMS adds newly eligible clinicians in selected areas CFR 2026.

Second, the same low back pain cost measure already exists in MIPS, inside the Rehabilitative Support for Musculoskeletal Care value pathway CMS 2025; our clinicians are scored on it whether or not ASM applies.

Third, the workflows ASM requires are things we should do anyway: a written collaborative care arrangement with at least one primary care practice, sending information back to the primary care physician, screening for health-related social needs, and a certified EHR CMS 2026.

Fourth, patient-reported outcome scores are the common currency: ASM's quality score, TEAM's fusion information-transfer measure from 2028, and every commercial bundle depend on them.

And fifth, commercial payers and employers copy Medicare. A documented, low-waste back-pain pathway with outcome data is what earns a preferred-provider position.

Four related items, briefly.

The NOPAIN Act gives temporary separate Medicare payment for qualifying non-opioid pain treatments in hospital outpatient departments and surgery centers, from 2025 through 2027, with the qualifying product list updated quarterly CMS 2024 CMS 2025. Our opioid-sparing protocols can therefore be partly paid for, which matters for outpatient fusions and decompressions.

MIPS value pathways: there is no spine-specific pathway, but the Rehabilitative Support for Musculoskeletal Care pathway contains the same low back pain cost measure that ASM uses CMS 2025, so our clinicians are already being scored on back-pain episode cost through MIPS.

CJR-X begins in 2028 as a national joint-replacement model and excludes TEAM hospitals CMS 2026; it is not spine, but the same case management and quality teams will be running both.

And the policy debate: a recent commentary in the American Journal of Managed Care argues that two-sided specialist risk will push small practices to consolidate AJMC 2026. It is opinion, not data, but it is a reason to build our measurement infrastructure early.

Finally, what I propose we do, and what I will own.

Measure what the models measure. Seven measures, one page, reviewed monthly.

For TEAM: fusion volume by DRG and by site, inpatient and outpatient, because the target price differs; length of stay and the share of patients discharged home rather than to a facility; thirty-day readmissions and emergency visits; and complications and harm events, which feed the quality score. TEAM hospitals receive claims data from CMS on their episodes, so the first task is to get that data to the service line every month CMS 2026.

Implant cost per case does not change Medicare episode spending, but it is the hospital's margin and a legitimate source of documented internal savings for gainsharing, so value analysis owns that line.

For ASM, TEAM's future fusion measure and commercial contracts: outcome scores before and after surgery, the Oswestry or PROMIS, collected in clinic.

And for the prior authorization programs: approval rate, days to decision, and how close each surgeon and pain physician is to the gold-card exemption.

What I will own as the physician lead.

I will translate the rules for the service line and keep this deck current; CMS publishes changes several times a year, and the 2027 physician fee schedule rule is due within weeks.

I will chair a monthly spine episode review: the dashboard, the outliers, every readmission, and one case each month in detail.

I will co-design the TEAM collaborator arrangement with administration and counsel: the quality criteria, the savings sources, and the paperwork, in writing and in advance as the rule requires.

I will standardise the clinical pathway: pre-operative optimisation, the discharge destination decided at booking, a call within forty-eight hours, and a two-week visit.

I will set documentation standards for WISeR and the outpatient prior authorization program, with templates that match Medicare's coverage policies, and track our clinicians toward the gold-card exemption.

And I will stand up outcome-score collection in clinic, and a back-pain pathway with primary care that would meet ASM's requirements if and when we are pulled in.

What I need from you is on the next slide.

What I am asking for in the first ninety days.

In the first two weeks, data: access to the claims data CMS sends us as a TEAM participant, and a named analyst, so we can build the baseline for fusion volume, length of stay, discharge destination and readmissions.

By the end of the first month, people: a small working group with case management, quality, revenue cycle, supply chain, nursing and the surgeons.

In the second month, the pathway: the optimisation checklist, the discharge destination decided at booking, the forty-eight-hour call, and documentation templates for the two prior authorization programs; and a first draft of the TEAM collaborator arrangement with counsel.

In the third month, our first monthly dashboard and episode review, with outcome-score collection live in clinic.

That is a modest ask with a measurable return: every avoided readmission and every facility discharge converted to home is money the hospital keeps under TEAM.

A slide for the inevitable hallway conversations, because much of what circulates about these models, including summaries I was handed while preparing this, contains errors.

ASM payment adjustments start in 2029, not 2028. ASM covers selected areas only, and Bergen, Hudson, Passaic and the Newark division are not among them. A fusion done in a surgery center does not start a TEAM episode. WISeR includes only one cervical fusion code, the outpatient ACDF is under a separate program, and lumbar decompression is delayed. And TEAM target prices are set per DRG or outpatient code rather than being site-neutral.

When in doubt, the CMS documents linked on the reference page are the authority, and I am happy to look anything up.

Five things to remember. TEAM is live and the risk is the hospital's. WISeR and the outpatient prior authorization program are live, and the facility needs the tracking number. ASM is the clinician's risk from 2027 in selected areas; not Bergen or Hudson today, but worth preparing for. The same clinical levers move all three. And gainsharing is how we align surgeons and the hospital, done properly. I will lead the work, and I would welcome a working group to do it with.

Every fact in this talk comes from these CMS documents, the Federal Register and the Code of Federal Regulations, read on October 18, 2026. The online deck links each one.

The deck stays online with the notes and every source. I will update it when the 2027 physician fee schedule rule is final and whenever CMS changes WISeR or TEAM. Questions.