Devalue The Doctor: The Response Of A Manipulated System To Orthopaedic Surgeons

Prem Ramkumar, MD, Forbes Contributor 

Not everything that counts can be counted, and not everything that can be counted counts.

We have lost sight of this truth along our journey towards value-based healthcare. The well-intentioned value equation represents a concerted systemwide effort to decrease healthcare expenditures while maximizing the quality of care rendered, but it opened the door for administrative misalignment with the art of medicine.

Despite recognizing that “the business of healthcare depends on exploiting doctors and nurses,” we continue to choose lean principles and line items over patients and frontline workers even in the midst of a pandemic.

In the eyes of the public, physician ownership of the cost conundrum was conflated with a false narrative rooted in physician atonement for their wealth and greed. The hundreds of anecdotal stories related to exorbitant costs from surprise billing, from questionable MRI scans to the out-of-network anesthesiologist, exacerbated the optics of the medical team and primarily positioned the doctor to be the scapegoat.

The entire healthcare team – doctors, nurses, social workers, technicians, therapists, advanced practice providers – absorbed the reprisal and unsurprisingly assumed ownership of the problem. After all, ownership remains a core tenet of patient care. However, the burden of fixing healthcare – a notoriously complex and purposefully opaque system – requires shared responsibility across all players.

Hip and knee replacement surgery represents one of the highest volume procedures paid for by Medicare, therefore one of the greatest expenses for the hospital and insurance administrator. This set the stage for joint replacement surgeons and their representative society – the American Association of Hip and Knee Surgeons (AAHKS) – to lead the way in policy and payment reform.  

Unlike other stakeholders in healthcare who intentionally obscure the cost of care in service of the bottom line, hip and knee replacement surgeons have a sacred contract with the patient and society above all. Doctors have a responsibility to ensure high quality care at a socially conscious price, and the evidence clearly indicates healthcare transformation is more likely to succeed when it is physician-led. As a result, AAHKS met federal representatives from the Center for Medicare and Medicaid Services (CMS) and Center for Medicare and Medicaid Innovation at the table knowing full well this would literally disrupt our day-to-day operations.

After a decade of working closely advising and developing successful alternative payment models for both Medicare and commercial payers, AAHKS then recruited nearly half the country’s hip and knee replacement surgeons into participating – the highest specialty participation rate among all newly introduced value-based programs. As a result of this Medicare and AAHKS partnership, patients did better and the cost of care dropped.

Having just witnessed surgeons and their teams run a four-minute mile, both federal and commercial insurance plans asked for more. As expected from any operations manager, hospital and insurance administrators began to approach patients undergoing hip and knee replacements as a commodity. The next step was to scale by lowering production costs.

Instead of questioning the steadily rising hospital fees and administrative costs, insurance plans honed in on devaluing the work of the surgeon and his or her team through a multi-pronged attack.


  1. Insurance companies now incentivize patients to undergo hip and knee replacement in the outpatient setting to avoid paying hospital fees during the admission. Not all patients are safe for this, but insurance plans reward it without absorbing any risk.
  2. The hours involved in medically optimizing a patient and planning postoperative care shifted from the inpatient admission to the preoperative period, where none of these efforts are financially captured.
  3. CMS decreased the work relative value units (RVUs) for hip and knee replacement by 5.4% under the Physician Fee Schedule despite documentation of additional work expenditures from involvement in value-based initiatives. Not only do these RVUs for hip and knee replacement fall below the 20th percentile of the recommended rates by the Revenue Value Scale Update Committee, surgeon fees account for 6% of the total episode cost and do not represent a significant cost driver. This RVU cut cascades to both private and public insurance plans.
  4. One commercial insurance company went as far to request reduction of RVUs under the false assertion that surgeons are doing less “work.” Not only are surgeons spending the same amount of time replacing hips and knees as they’ve always been, the one less night patients are spending in the hospital are due to the preoperative diligence and increased postoperative outpatient monitoring by the surgeon team.


Directing these disincentives and misplaced budgetary cuts towards the same surgeons who guided federal and commercial insurance companies through payment reform – only to be targeted in an ongoing pandemic – feels more personal than “business as usual.” Instead, it undermines years of collaboration and commitment to value-based initiatives and scapegoats the surgical team for the flaws of a manipulated system. While many hospital and insurance administrators were happy to accept counsel as goodwill, they propped up a system that turned a blind eye to the reality of increasing hospital payments and administrative costs.

The cost-conscious message from above trickles down to physicians and their practices, incentivizing the healthcare team to follow their lead by prioritizing the bottom line. In a poll of 1,120 patients who underwent hip or knee replacement, patients felt that surgeons should receive 14 times more for the operation than they do currently. Many patients remarked they would expect surgeons to stop accepting Medicare upon learning the actual surgeon reimbursement accounts for 6% of the total episode costs. If this were to occur, our underserved will be disproportionately affected and health inequities will worsen. The doctor-patient relationship could become a historical footnote as we reward doctors for spending less time at the bedside and disincentivize these life-altering operations.

The story of hip and knee replacement surgeons underscores a harsh reality: doctors may be invited to the table to solve the system’s problems, but it doesn’t mean they won’t wind up on the menu.

On the surface, a value-based system seems to be an elegant and scalable solution for product-centric businesses. Despite our best attempts to find a perfect metric that encapsulates healthcare services, we have come up short. Some have forgotten that in medicine the “product” is human beings caring for human beings. More administrative regulations, more business management principles, and more metrics will never change the square peg that is business administration or the round hole that is the art of medicine.

The professionals who have always prioritized patients over profits are what count in medicine, even if this cannot be easily counted. Devaluing the doctor and moving the goalposts for the whole medical team may tidy up the balance sheet, but the current trajectory of “value-based care” hardly leads us to a standard of care based on our values.