The economics of specialty medicine are bending, and one of neurosurgery's most senior voices says the breaking point is close. Physician fees have fallen roughly 30 percent over the past 20 years, John Golfinos, MD, chair of neurosurgery at New York City-based NYU Langone Health, told Becker's Spine Review in an interview published August 14, 2026. He argued that reimbursement for high-acuity work no longer reflects the training, risk, or time behind it.
Dr. Golfinos put a number on the squeeze. Medicare pays a physician about $2,200 for a craniotomy to remove a brain tumor, he said, and private insurers typically negotiate around 150 percent of the Medicare rate. That may sound like a premium, he noted, but it still does not cover the true cost of sustaining a subspecialty practice. These figures are his own estimates rather than a formal dataset, though the broad trend is documented elsewhere, as noted below.
The response is already visible, he said. More surgeons are opening physician-owned ASCs to capture facility fees, and some, especially in the suburbs around New York, have stopped taking insurance entirely to live on out-of-network rates. The strain lands hardest away from large academic centers, where smaller hospitals may struggle to pay neurosurgeons enough to keep emergency rooms and level 1 trauma coverage staffed.
Key Takeaways
Physician fees have declined roughly 30 percent over the past 20 years, according to Dr. Golfinos, who said a "crisis point" is likely "sooner rather than later." (Becker's Spine Review, Aug 14, 2026.)
He cited Medicare paying about $2,200 for a brain-tumor craniotomy, with private payers around 150 percent of Medicare. These are his examples for high-acuity neurosurgery, not averages across all procedures or specialties.
Surgeons are responding by opening physician-owned ASCs to capture facility fees, or by moving out-of-network and cash-only.
The pressure is worst outside large academic medical centers, threatening emergency and level 1 trauma coverage at smaller hospitals.
Independent context: the American Medical Association reports Medicare physician payment has effectively declined 33 percent from 2001 to 2025 when adjusted for inflation, corroborating the direction of Dr. Golfinos's estimate.
What Exactly Did the Surgeon Say?
In the August 14 interview, Dr. Golfinos recalled that the neurosurgery chair role at NYU Langone once paid roughly what the No. 2 job at Goldman Sachs paid in the late 1980s, and that physician compensation has not changed since that day while finance pay climbed sharply. From there he estimated that physician fees are down roughly 30 percent over 20 years and warned that neurosurgery and other high-acuity subspecialties are heading for a reckoning as reimbursement keeps sliding. It is one senior surgeon's view, grounded in his own practice economics.
Are These Numbers Verified?
Two things are worth separating. The specific figures, about $2,200 for a craniotomy, roughly 150 percent of Medicare for private payers, and a 30 percent decline, are Dr. Golfinos's own estimates offered in an interview, and Becker's presents them as his statements rather than an independent measurement. The broad trend, however, is well documented. The American Medical Association reports that Medicare physician payment has effectively declined 33 percent from 2001 to 2025 after adjusting for inflation. So the direction and rough magnitude are corroborated, even if the individual dollar figures are illustrative.
Why Does a Neurosurgery Pay Problem Matter to Other Specialties?
Because the mechanism is shared. The same fee-schedule pressure that squeezes neurosurgery also reaches orthopedics, pain management, anesthesia, and other procedure-heavy specialties, with anesthesia facing its own well-publicized reimbursement cuts. When the payment per procedure keeps drifting down, the revenue a practice actually collects on work it already performs becomes the difference between viable and not.
What Are Physicians Doing About It?
Three moves, per the article. Building physician-owned ASCs to earn a facility fee on top of the professional fee. Going out-of-network or cash-only to escape declining contracted rates. And, Dr. Golfinos predicts, eventually leaving Medicare in larger numbers, which he believes is the only thing that will force CMS to act.
What This Means for Your Practice
You cannot set the Medicare conversion factor. What you can control is how much of the earned rate actually reaches your account. When the price per procedure falls, every underpayment, denied claim, miscoded encounter, and uncaptured facility fee costs proportionally more. Revenue integrity stops being back-office hygiene and becomes a survival margin.
This is the work Cosentus does for the specialties we serve, including orthopedics, wound care, pain management, anesthesia, behavioral health, cardiology, and ASCs. We make sure coding is accurate and complete, denials are worked and prevented, payer contracts are held to their terms, and, for physician-owned surgery centers, facility-fee revenue is captured cleanly. When the rate environment tightens, disciplined RCM is how a practice keeps the dollars it has already earned.
Frequently Asked Questions
Is the 30 percent decline an official statistic?
It is Dr. Golfinos's estimate, given in a Becker's interview. The closest official figure is the AMA's finding that Medicare physician pay fell 33 percent from 2001 to 2025 adjusted for inflation, which supports the same trend.
Does the $2,200 craniotomy figure apply to my specialty?
No. It is a specific example for a brain-tumor craniotomy under Medicare, used to illustrate high-acuity neurosurgery economics. Your rates depend on your specialty, codes, payer mix, and contracts.
Is this a political or policy story?
No. It is about reimbursement economics and how physicians are adapting. It does not turn on any single administration's policy.
Can better billing offset a falling fee schedule?
It cannot replace a rate cut, but it can recover the meaningful share of earned revenue that most practices lose to denials, underpayments, and coding gaps, which matters more as margins compress.
What can a practice do this quarter?
Quantify your denial and underpayment rate, audit high-volume codes for accuracy, confirm payers are paying contracted rates, and, if you run an ASC, verify facility-fee capture. An RCM partner can run all of this if you lack the bandwidth.
Talk to Cosentus
You cannot control the fee schedule, but you can control how much of it you keep. Cosentus helps specialty practices and surgery centers capture, defend, and collect every earned dollar as reimbursement pressure grows. Talk to our team at cosentus.com/contact or call +1 (877) 266-9040.