Value-based care has become one of the most pressing challenges, and opportunities, in orthopedic and spine surgery.
Rising costs, increasing case complexity and shifting expectations from patients and payers are forcing health systems to rethink how they deliver care long before a patient enters the operating room.
Amit Jain, MD, chief of minimally invasive spine surgery and director of value-based care at Baltimore-based Johns Hopkins Medicine, believes the most meaningful gains aren’t coming from bigger implants or flashier technology, but from disciplined, systemwide redesign of the entire care continuum, from preoperative optimization to surgical decision-making to post-discharge navigation.
His approach is reshaping how spine programs think about quality, consistency and true value in a rapidly evolving specialty.
A clear definition of value
Value-based care can mean different things depending on the stakeholder, but Dr. Jain keeps the concept grounded.
“Value really means improving quality, reducing costs and then also improving the patient experience. You have to be able to do all three of those things simultaneously,” he told Becker’s.
He views quality and experience as upstream drivers that reduce costs naturally.
“Any intervention or any program that really improves quality will also likely reduce costs because it would avoid a lot of preventable complications or preventable events that actually increase our costs,” he said.
That belief drives the system’s emphasis on strengthening the perioperative experience, long before surgery.
Where value begins
Although procedural tools and intraoperative techniques are more advanced than ever, Dr. Jain said outcomes often reflect what happens before surgery. In spine care, he described a clear pattern: when patients are medically optimized, they do significantly better.
“Patients who do well, it’s not necessarily the technical factors. If the patient has not been optimized preoperatively and we have not optimized their bone density, their chances of doing well after surgery are going to be rather slim,” he said.
To improve readiness, Johns Hopkins uses structured pathways that focus on risk assessment, medical optimization and education.
“It’s really important to optimize, select the right patient, reduce risk and mitigate that as much as possible before getting them to the hospital,” he said.
For patients, that preparation makes the entire process “much more seamless.”
Three pillars of improvement at Johns Hopkins
Dr. Jain said Johns Hopkins has seen the clearest gains in three interconnected areas: risk stratification, preoperative education and care navigation.
Risk stratification has become a central part of the process. For example, every patient undergoing an instrumented lumbar fusion now receives a [dual-energy, X-ray absorptiometry] scan, so the team can identify bone health issues early.
“If it is poor or if they have osteoporosis, we send them to an optimization clinic and get them on the right medications to fix their bone health prior to considering surgery,” he said.
Untreated bone health significantly increases the likelihood of nonunion and hardware failure, making early intervention critical.
Preoperative education is the second area driving improvement. Standardized programs help prevent avoidable ED visits, reduce postoperative uncertainty and give patients a clearer understanding of what recovery will involve.
The third area is care navigation. Johns Hopkins increasingly uses MyChart to streamline communication and support patients throughout recovery.
“We have really leveraged MyChart for patient messaging, so they are not calling the doctor’s office waiting for someone to call them back,” he said. “It is all seamless.”
Aligning surgeons around consistency
Achieving value-based care requires alignment among surgeons and departments, a challenge for any large academic center. Dr. Jain said consistent care pathways reduce unnecessary complexity.
“It is really important to have a standardized pathway for patients so that you reduce heterogeneity in care delivery,” he said.
He offered implant selection as one example.
“If you have surgeon A using one type of implant, surgeon B using a totally different type of implant and surgeon C using another type, that increases your inventory, increases your availability needs and creates confusion for the staff,” he said.
Johns Hopkins now limits its spine implant vendors to three, a move that preserves choice while improving efficiency.
Cultural adoption, however, takes more than policy changes.
“There are a lot of people who say they have always practiced a certain way and do not want to change,” he said. Presenting data and showing clear benefits has been crucial.
One senior colleague of Dr. Jain summarized the mindset with a phrase that stuck: “Yes, you can teach your old dog new tricks.”
Technology as an accelerator of value
Dr. Jain believes technology plays an essential role in every phase of care, though its purpose is to amplify clinical judgment rather than replace it.
Before surgery, AI-powered education platforms help clinicians deliver more consistent, detailed guidance.
“Being able to amplify or uphold myself using this AI platform is tremendously helpful,” he said.
Johns Hopkins now uses AI-created patient handouts for preoperative education, which patients, he noted, “love it.”
In the OR, technology has transformed safety and precision, especially in complex deformity cases.
“Neuromonitoring has completely changed the way we do scoliosis surgery,” he said. “Robotics, navigation and blood-sparing tools further strengthen accuracy and reduce complications.”
After surgery, technology continues to support patients as they transition home or to rehab.
“Being able to make that journey more seamless through education and through care navigation platforms is super helpful,” he said.
A bold proposal: multi-surgeon case review
If he could change one aspect of current quality or payment structures, Dr. Jain said he would require multi-surgeon case review for every spine patient.
“I would ask that each spine case be reviewed by a panel of surgeons, and that is the practice we have instituted in our institution,” he said.
Every Friday, from 6 a.m. to 9 a.m., five to 10 Johns Hopkins spine surgeons meet to review upcoming cases. The collaborative model, he said, is transformative.
“It is like having ten opinions for your mom,” he said. “Imagine the depth of knowledge that is exchanged.” He believes national adoption would significantly improve appropriateness, planning and safety. “If I was the CMS head, I would say every Medicare patient should have that.”
Why it works at Johns Hopkins
Although Johns Hopkins is known for its surgeons, Dr. Jain said the success of its value-based approach depends on a broader ecosystem.
“It is not just the surgeons. It is the whole village,” he said, citing dedicated nurses, OR technicians, perioperative staff, physician assistants and nurse practitioners.
Their teamwork creates a culture of safety and shared purpose.
“It takes all of those people working together to care for patients and focus on quality and a good experience,” he said.
Looking ahead
For Dr. Jain, value-based care is not a fleeting initiative. It is an ongoing commitment to doing what is right for patients while reducing avoidable cost and variation. “Any value program that drives the top side of the equation also drives down the bottom side, which in turn improves net value,” he said.
As technology evolves and pathways mature, Johns Hopkins plans to continue refining its model.
