Spine surgeons can now operate on patients they once had little choice but to turn away. Whether hospitals and practices can afford to deliver that care is becoming a more difficult question.
Keven Burns, MD, an orthopedic spine surgeon at the Scottsdale-based Spine Institute of Arizona, sees the tension in adult degenerative scoliosis, where treatment can range from a targeted decompression to a major spinal reconstruction.
Minimally invasive techniques are expanding the pool of surgical candidates. Robotics, navigation and patient-specific implants are creating new possibilities for complex cases. But those advances come at a cost that reimbursement may not always cover.
“We have awesome technology right now, but financially, can we even implement it?” Dr. Burns told Becker’s.
For him, the answer depends partly on whether surgeons can resist doing more than a patient needs, and whether the healthcare system can sustain the care that cannot be simplified.
When less surgery is enough
A spinal curve can look severe on imaging without necessarily warranting an extensive operation. Dr. Burns begins by identifying what is actually limiting a patient’s daily life. Leg pain caused by nerve compression, difficulty walking from spinal stenosis and an inability to remain upright because of spinal imbalance may all occur in patients with degenerative scoliosis, but they do not call for the same treatment.
Someone with central stenosis may benefit from decompression alone. A patient with nerve compression caused by an asymmetrically collapsed disc may need a fusion at only one level, leaving the rest of the curve untreated. More extensive reconstruction becomes an option when the deformity itself contributes to functional decline.
“I’d much rather not do a huge T10-to-pelvis open reconstruction,” Dr. Burns said. “For a lot of patients, that’s overkill. They don’t need it.”
Although his practice emphasizes minimally invasive surgery, he does not believe the technique should dictate the treatment. The priority is addressing the source of a patient’s symptoms with the most appropriate operation, rather than pursuing a particular approach simply because it is available.
That judgment is becoming more important as surgeons gain the ability to treat patients who previously had few viable options.
The patients surgery used to leave behind
For older adults with significant medical conditions, the risks of extensive reconstruction have historically made surgery difficult to justify. Less invasive procedures are giving some of those patients a way to address debilitating symptoms without undergoing a major operation.
Dr. Burns said the pool of surgical candidates is expanding as surgeons develop less disruptive approaches, even though the underlying reasons to recommend surgery have not necessarily changed.
Some of those procedures are also moving beyond hospitals. Dr. Burns expects appropriately selected patients with degenerative scoliosis to increasingly undergo outpatient decompressions and limited fusions at ASCs, including certain single-level lateral procedures with percutaneous posterior fixation.
He sees potential for more multilevel procedures to follow as techniques and supporting evidence develop. Extensive reconstructions, however, will continue to require hospital resources.
The hospital’s calculation
As more straightforward spine procedures move to ASCs, hospitals may be left with a greater concentration of expensive reconstructions requiring substantial operating room time, specialized personnel, costly implants and, in some cases, prolonged postoperative care.
Dr. Burns worries that declining reimbursement, potential site-neutral payment changes and Medicare’s Transforming Episode Accountability Model could make hospitals more selective about accepting these cases, particularly when the operations cannot safely move to outpatient settings.
At the same time, the tools used to perform complex surgery are becoming more sophisticated and expensive. Robotics, advanced navigation and patient-specific implants can improve what surgeons are able to plan and perform, but adopting them also creates new financial demands.
Dr. Burns sees a growing imbalance between the parties paying for, supplying and using those technologies. He pointed to hospital payment arrangements for certain qualifying patient-specific implants. While manufacturers can benefit from premium implant pricing and hospitals may receive additional reimbursement, surgeons often absorb the extra time required for preoperative planning without a corresponding increase in professional payment.
“The surgeon gets nothing actionable except for good outcomes,” he said.
He also questions how long favorable reimbursement for newer implants will last as utilization rises. For Dr. Burns, that makes evidence of lasting clinical benefits and financial value increasingly important. Without it, hospitals may struggle to justify continued investment in these technologies.
The costs of complex spine care, however, are not limited to the technology used in surgery.
The investment nobody sees
At the Spine Institute of Arizona, one of those less visible investments is a dedicated bone health clinic.
Dr. Burns said patients preparing for fusion or deformity correction often need osteoporosis evaluation and treatment, but coordinating that care through outside specialists can be difficult. The practice decided to bring more of it in-house.
A physician assistant now oversees weekly clinics for compression fractures and osteoporosis, along with a pathway to optimize bone health before surgery. For patients facing extensive reconstruction, that preparation can be critical to a successful outcome, even when it requires months of treatment and follow-up.
“It’s not the pretty stuff,” Dr. Burns said. “It’s not the fun stuff to do, and it takes a lot of time.”
It also represents the kind of investment that is difficult to capture in a surgical reimbursement rate. As the number of older adults seeking spine care grows, Dr. Burns believes practices will need more deliberate systems for managing patients before they reach the operating room.
At his practice, that means separating patients into treatment pathways based on their symptoms and surgical needs. Those who can be managed without surgery work with pain management specialists. Patients who need decompression or a limited fusion can follow a more streamlined process, while extensive reconstructions receive additional planning and optimization. The aim is to preserve time and resources for the patients who need them most, without making the operation itself more extensive than necessary.
The life on the other side of surgery
In Arizona, Dr. Burns’ patients have their own definitions of a successful spine operation. Some want to play pickleball again. Others want to ride horses or get back on the golf course.
Those goals matter when deciding how much surgery is necessary. A targeted decompression or limited fusion may preserve activities that a more extensive reconstruction could restrict. For Dr. Burns, correcting the deformity is not necessarily the same as giving a patient the outcome they want.
That distinction carries growing weight as older adults remain active longer and arrive with more complex surgical needs. Meeting those expectations will require practices to become more deliberate about patient selection, preoperative preparation and site of care.
The challenge, Dr. Burns said, is building a system that can support that level of individualized care without making it financially unsustainable.
For the patient hoping to get back on a horse or finish another round of golf, the measure of success is not how much of the spine was corrected. It’s what life looks like afterward.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
