Tertiary and quaternary academic medical centers absorb the hardest spine cases in the country, and the pressure on them is building faster than the resources to address them.
“I worry about the increasing pressure on tertiary and quaternary academic medical centers,” said Rajiv Sethi, MD, PhD, professor, spine division chief, co-director of the University of California San Francisco spine center and the system’s medical director of value-based musculoskeletal initiatives. “It’s already palpable.”
Dr. Sethi, who treats complex spinal deformities, infections, cancer and conditions requiring revision surgery, sees an aging patient population, a shrinking supply of spine surgeons and payment models that cap costs while demand climbs. His biggest worry is access.
“The same patient that I can see today may not have access to me in 10 years or 15 years, because there are going to be fewer of me,” he said.
His fix starts with how value-based care should work and ends with how payers should support the centers that take on the most complex patients.
What value-based spine care should look like
For Dr. Sethi, value-based healthcare means “providing the right care to the right patient at the right time at the right location.” In a large health system, that sends routine cases to settings where patients get in and out easily and care teams can control the “noise.” Spinal deformity, spinal oncology and complex reconstruction go where clinicians can control the variables that lead to complications.
“They’re both value-based healthcare; they’re just different,” he said. “There’s no one size fits all in value-based healthcare.”
He said the model gets maligned as cookbook medicine or a way to control physicians. “When it’s practiced effectively, it should lead to happier doctors, happier patients, happier payers,” he said.
That includes deciding who should not have surgery. Dr. Sethi said spine surgeons can do a better job of selecting, optimizing and declining patients, but that responsibility should stay with physicians.
“I want that job to lie with the medical profession and not with the payers and not with the governments,” he said.
The work is complicated by a fee-for-service system in which many spine conditions don’t respond to nonsurgical care, leaving patients few alternatives to interventions, medications or surgery. In his systemwide role, Dr. Sethi works with scientists, health economists and rural care experts on how networks and AI can give a rural patient the same quality of care available in San Francisco or New York.
Why the strain is already ‘palpable’
The pressure starts with demand. As the population ages, more patients will need spine care, while the supply of neurosurgeons and orthopedic surgeons shrinks.
“We are going to be inundated with these patients,” Dr. Sethi said.
Adult spinal deformity will grow with that population, and those cases demand the most: deep expertise, multidisciplinary teams and advanced technology. Resources aren’t rising to match.
“There is not an enhanced resource allocation for these cases,” he said. “That’s where the strain on the tertiary and quaternary academic medical centers becomes even more extreme.”
Revision surgery adds to that load. The most common revisions Dr. Sethi performs involve fusions done decades ago, before modern alignment principles were understood, where the segments above and below have since broken down. Others follow a fusion that never healed, leaving patients with broken rods and lost correction.
Some revisions follow a smaller procedure that bought a patient years of relief before a major correction. Dr. Sethi said those shouldn’t automatically be read as failures. If a single-level operation gives a patient three to five years without a major fusion, “I think that was a well-done operation,” he said.
Payment models are tightening at the same time. CMS’ Transforming Episode Accountability Model doesn’t apply to spinal deformity today, but Dr. Sethi expects it will, and he expects accountability for readmissions and revisions to grow.
“So we’re cost-constrained, but yet facing more demand,” he said.
Without clear pathways that define when a case belongs at an academic center and when it doesn’t, he warned, the U.S. could move toward rationed care, with patients waiting many months to see a spine surgeon, as they do in the British or Canadian systems.
The fix: Centers of excellence and fewer prior authorization hurdles
Dr. Sethi would start by clearing a path for the patients who already need academic care. If a patient is referred to a tertiary or quaternary center and a team of experts reviews the case, he said, prior authorization shouldn’t stand in the way of the procedure.
He has also advocated for enhanced reimbursement for centers that deliver centers of excellence-level care and can prove it.
“If they can prove that they are reducing readmissions, reducing complications, getting patients out of the hospital faster, getting them to work faster, there should be enhanced reimbursement,” he said.
That approach has precedent. Dr. Sethi pointed to early centers of excellence work in Seattle dating to 2013, which brought in patients with complex spine problems from all 50 states.
“This needs to be nationalized,” he said.
He envisions a quaternary center in every region with a track record for the most difficult cases, paid enough to keep doing that work and to keep improving.
Keeping the ‘organism’ healthy
Care delivery is only part of what academic centers carry. They also study what works, test new technology and approaches for complex problems, train the next generation of surgeons and work with payers and government on policy.
“The load is all falling on places like UCSF,” Dr. Sethi said. “So we are basically carrying a large boulder for American society.”
Keeping that work going requires a specialized look at how it is funded, he said.
“The only way to keep it healthy is to make sure that the organism is given nutrition,” he said.
It also requires people. Dr. Sethi said he spends much of his time with residents, fellows and young physicians, encouraging them to pursue academic careers in teaching and research.
Where it could go
Despite the pressure, Dr. Sethi is optimistic. He believes AI and other technology can triage patients more effectively, ease physician burnout and steer each patient to the right place.
If that happens, he said, the patients filling a UCSF spine surgeon’s clinic would be the ones who truly need to be there.
“We are just on the cusp of getting the correct patient in front of the correct doctor at the right time,” he said. “That is the crux of our current issue.”
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