On April 1, the University of California, San Francisco Health’s department of orthopedic surgery appointed Rajiv Sethi, MD, PhD, to three positions: chief of orthopedic spine surgery, co-director of the UCSF Spine Center and UCSF system medical director of value-based musculoskeletal initiatives.
The multihyphenate sits at the intersection of clinical excellence, health economics and systemwide transformation, and the mandate is not simply to lead a program. It is to rethink how spine care is delivered, measured and scaled.
“I think we can elucidate a better way and help identify what the best system is for the management of most spinal problems,” Dr. Sethi told Becker’s.
At UCSF, he sees the rare ability to bring together surgical, nonoperative and research expertise to define that system, and then expand it far beyond a single institution.
A model built for scale
Dr. Sethi’s approach builds on the multidisciplinary “Seattle Spine Team” approach he helped pioneer at Virginia Mason Medical Center, which aligned specialists across disciplines to deliver coordinated, outcomes-driven care.
While that model proved effective in a smaller, highly coordinated environment, UCSF presents a fundamentally different opportunity.
“Our model can be enhanced,” Dr. Seth said. “The stakeholder alignment is important, and that has to be one of my first priorities.”
At UCSF, the goal is not just coordination. It is to scale.
“The UCSF model will continue to grow as a national and global model for the best spine care,” he said.
That shift changes the stakes. Instead of optimizing care for a defined population, the challenge becomes building a system capable of delivering high-quality spine care to patients across regions, and in some cases, across borders.
The central problem: access
For Dr. Sethi, the defining issue in spine care is not a lack of innovation. It is a lack of access to the right care, at the right time, in the right setting.
His objective is to build systems that expand access without compromising quality or safety.
“Enhancing patient outcomes should be the goal of the healthcare system,” he said, describing care that is both cost-effective and scalable to more patients.
At UCSF, that means rethinking how patients enter and move through the system, from local referrals to complex national and international cases. It also means using the institution’s already-broad footprint to deliver care outside of traditional tertiary settings when appropriate.
“We have to think about taking care of more people in a more cost-efficient manner,” Dr. Sethi said.
Where spine care goes wrong
Despite advances in technology and technique, Dr. Sethi sees a persistent flaw in how spine care is delivered.
“The yesterday care model of spine is to unfortunately overutilize spinal procedures that don’t work,” he said.
That overuse, he noted, exists across the spectrum, from injections to major reconstructive surgeries, and results from a failure to consistently align treatment decisions with evidence or outcomes.
In its place, he envisions a model centered on accountability and outcomes, where care is guided by data and concentrated in centers capable of delivering consistent results.
“The future care model should focus on bringing patients to designated centers of excellence where these procedures are done for evidence-based reasons, and the best outcomes are delivered,” he said.
In that model, value-based care is not about doing less. It is about doing the right work, more effectively.
Standardization as a strategy for growth
A key lever in that transformation is standardization.
By establishing evidence-based pathways and reducing unnecessary variation, health systems can eliminate delays, avoid redundant testing and move patients through care more efficiently.
“If you have standard work embraced, where all patients get appropriate treatment algorithms that are as evidence-based as possible, you remove wasteful processes,” Dr. Sethi said.
That approach enables a single spine center to operate across multiple levels of care, serving local patients while also functioning as a referral hub for more complex cases.
For patients with advanced conditions such as adult spinal deformity, that concentration of expertise is essential.
“There are not that many centers around the United States that have embraced value-based care processes and shed fee-for-service biases in care delivery,” he said.
Redefining value across the system
In his system-level role, Dr. Sethi is tasked with expanding value-based musculoskeletal initiatives across UCSF.
That effort goes beyond cost containment. It requires aligning outcomes, safety and patient experience with care delivery.
It also requires shifting care to the most appropriate setting, including outpatient environments and technology-enabled pathways that reduce reliance on high-cost facilities.
A leadership gap in healthcare
For Dr. Sethi, one of the most pressing challenges is not clinical; it is structural and born out of a growing disconnect between those delivering care and those shaping how it is delivered.
“Physicians are more and more in the back of the room on these discussion points, and they should be sitting in the front row leading the discussion,” Dr. Sethi said. “Often the person making major decisions about healthcare delivery has substantially less education and credibility and doesn’t face patients and families on a daily basis.”
At the root of that issue is a lack of training in health economics, a gap that leaves many physicians unprepared to engage in decisions about cost, value and resource allocation.
“Training in health economics for medical students is abysmal currently,” he said.
Consequently, decisions about care delivery are made absent sufficient clinical input, creating misalignment which ripples across the system.
Training a different kind of physician — one with financial savvy
Addressing that gap is central to Dr. Sethi’s long-term vision. He plans to integrate health economics into the training of residents and fellows at UCSF, equipping future physicians to engage more effectively in system-level decision-making.
“If I’m successful in integrating health economics modules into the curriculum for our orthopedic and neurosurgical residents, then perhaps we can get that into the medical school curriculum too,” he said.
The goal is to produce clinicians who are not only technically skilled, but also possess business sense.
“You send a surgeon into the arena with minimal training on how things get paid for and expect them to thrive in environments where cost-containment threatens their ability to take the best care of patients,” Dr. Sethi said.
Defining the next five years
Looking ahead, Dr. Sethi measures success in clear terms: expanded access, improved outcomes, reduced complications and demonstrable cost-effectiveness.
He wants UCSF to serve as a model. “I want to enhance the training of younger physicians, so they are leading national discussions in this area,” Dr. Sethi said. “They can also help organizations avoid the fallout of decisions made by folks who change jobs every 18 to 24 months and have no contact with the patient.”
The goal is not just to improve his designated program, but to redefine spine care in healthcare at large, who has access to it and who ultimately leads the decisions that shape it.
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