As Americans live longer and stay more active into their 70s and 80s, more of them are undergoing hip and knee replacements — and, increasingly, complex spine surgery to correct deformities that can worsen with age. But Christopher Ames, MD, director of spinal deformity and spine tumor surgery at San Francisco-based UCSF Health, said health systems that treat these patients are approaching a breaking point tied to how the procedures get reimbursed.
“Healthcare rationing will certainly come to the U.S.,” he said. “There’s no question.”
Underlying it is a more fundamental issue: Adult deformity surgery is expensive and often performed on older patients, a population heavily reliant on Medicare. This combination, Dr. Ames said, is already straining hospitals willing to take on these cases.
“Many private hospitals don’t feel that they’re getting sufficient reimbursement at Medicare rates,” Dr. Ames said. “This is the real problem.”
He described a conversation with a physician at another hospital system that treats its deformity program as a “marquee product” it can afford to lose a few million dollars on for prestige and marketing purposes — not as a line of business expected to break even. Add in the additional cost of custom implants and bone-healing biologics needed for older patients with poor bone quality, he said, and the margins on many of these cases disappear entirely.
“The margins in those cases disappear and they’re money losers,” he said.
Smaller hospitals opt out
According to Dr. Ames, the practical effect is that fewer hospitals want to be in the adult deformity business at all, even as the patient population needing this care grows. The complex nature of spinal deformity surgery carries an elevated risk of complications, prolonged recovery and repeat operations. He said the burden of the risk will be something smaller hospitals might not be able to shoulder.
“It’s really only the big tertiary hospitals and many of the public hospitals that are staying in this business,” he said.
Large academic medical centers such as UCSF Health can negotiate higher Medicare rates than smaller, private facilities, Dr. Ames said. Even so, he said, those same large hospitals still prefer higher-margin, shorter-stay procedures, leaving complex, revision-heavy deformity cases as a financial outlier even within institutions equipped to handle them.
Predictive modeling as a partial fix
Dr. Ames said his team’s work on predictive models and digital twins is, in part, a direct response to this financial pressure — an attempt to ensure limited healthcare dollars are spent on the patients most likely to benefit.
“If you can best design the operation, you can best predict the outcome, you can best predict the complication, and a healthcare system like Medicare in the U.S. — or the NHS [in the U.K.] — says, ‘Look, we have this much money to spend on this condition,’ then we can optimally select the patients who are most likely to benefit at the least cost,” he said.
Still, he was clear that better modeling alone will not resolve underlying reimbursement pressures.
“Some reckoning is going to have to come from the population that says, ‘Look, we’re all getting older. We need to pay for these operations that will sustain us,'” he said.
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