If Patients Knew: Surgeon Stewardship Versus Balance Sheet Bureaucracy In Orthopaedic Surgery, by Dr. Prem Ramkumar

“My total hip replacement in both legs has changed my life,” entrepreneur Mark Cuban told me when asked about his experience as a patient. “The biggest mistake I made was that I waited too long.”

You don’t have to be a business savant to appreciate the return on investment of being able to move pain-free again. Nor do you have to be exceptionally wealthy to access a joint replacement.

You just have to be in touch with the practice of medicine.

While millions of Americans with artificial joints would echo Mr. Cuban’s comments, access to this surgery is now at risk because of the increasingly tangled web of bureaucracy that stunts healthcare. The alignment of health insurance plans with hospital administrators who prioritize profits – instead of the physicians who prioritize patients – embodies the paradox of a system managed by leaders who broker “value-based care” without participating in the value of our care.

Hip and knee replacements are among the most frequently performed operations with projections approaching an annual volume of 2 million in the U.S. alone. Despite earning its reputation as “the operation of the century,” hip and knee replacement surgery has become a victim of its own success. How surgeons arrived at this juncture speaks volumes of the misalignment between the practice and business of medicine.

Understand that discussing money is uncomfortable for everyone in medicine.

Patients depend on our expertise for diagnosis and treatment, but we in medicine avoid the elephant in the room and outsource most matters related to cost and financial consideration. Behind the curtain of clinical medicine, an entire industry of third-party players in hospital and insurance administration exist to orchestrate the business of healthcare and absolve us from our collective discomfort.

Though health insurance was popularized as a jobs incentive in the post-World War II era, removing finances from the doctor-patient relationship was ethically palatable. The culture of medicine even extends this discomfort into our personal lives. To this day in medical school, considering future earnings before deciding a specialty is considered taboo. While personal and professional satisfaction should guide any career decision, doctors discourage ourselves at the very outset from considering financial realities for both ourselves and our patients.

Even if doctors could overcome this institutionalized discomfort, administrative hospital and insurance leaders who miraculously hold the reins in clinical medicine have engineered an intentionally opaque – yet codependent – system that bypasses the physician. In the case of alternative payment models for hip and knee replacement, the Center for Medicare and Medicare Services (CMS) preferentially upheld the hospital-led program (Comprehensive Care for Joint Replacement [CJR]) over the physician-led program (Bundled Payments for Care Initiative [BPCI]). Despite the evidence indicating BPCI resulted in nearly twice the saving as CJR, profit-oriented insurance plans aligned with profit-oriented hospital administrations and excluded the doctors from the negotiating table. The adage “follow the money” simplifies the complexity of every industry but medicine – hamstringing the medical team from identifying and mitigating the issues that directly impact their patients and workflow.

Our discomfort in managing our own business leaves us complicit in upholding this myopic system. By focusing on patient care and abdicating our fiscal responsibility to the industry, we signaled apathy to administrative third parties. We ignored both commonsense and evidence that convincingly underscores healthcare is best led by those with a finger on the pulse of the actual practice of healthcare.

If discussing money was uncomfortable, imagine needing to justify the work of doctors or nurses to nonclinical leaders with patient care at stake. Patients are obviously affected by their medical team, but that medical team is affected by its administration. Failure to protect our medical team is a failure to protect our patients.

When the practice and business of healthcare remain this disparate, it’s easy to mistake value for excellence.

Revisit the fate of orthopaedic surgeons who replace hips and knees for a living. Year after year, surgeons and their teams reinvented themselves to meet milestone after milestone for cost-conscious federal programs. Quality was maintained or improved while costs were reduced. This good faith effort was instead considered by insurance and hospital administrators as evidence of prior inefficiency, complacency, and “waste.” Rather than congratulating the orthopaedic surgeons, nurses, advanced practice providers, anesthesiologists, technicians, and environmental services personnel for running a brilliant four-minute mile, administrators and insurance plans demanded it be done in three minutes.

When the Resource-Based Relative Value Scale was first integrated into the Medicare program by CMS to establish physician reimbursements, one of its stated goals was to equalize payment rates between surgical procedures and nonsurgical – or “cognitive” – treatments in medicine by decreasing the rates of “historically overvalued specialty procedures.” The combination of a reproducibly excellent product (restoring painless joint function) with an increased need from an aging population has Medicare and commercial plans concerned enough that they are willing to deter the operation by any means necessary – from disincentivizing patient access and erecting bureaucratic barriers to gaslighting surgeon teams into questioning the “value” they provide.

Despite already saving the economy and commercial plans millions of dollars while simultaneously improving patient lives, administrators decided to slash surgeon team fees – which only encompass 6% of the actual total cost of joint replacement – to the point that a day of replacing hips and knees is slated to be economically equivalent to a day of routine office visits by 2024. Meanwhile, payments to the hospitals themselves for the joint replacements continue to rise. Now surgeons are faced with a conflict of interest more humiliating than their own devaluation: help the patient or bankrupt the practice. 

While the patients with a hip or knee replacement may be better suited to communicate the significance of walking pain free again, minimizing and degrading the care team’s work as a non-cognitive commodity is failing to understand the process.


  1. Consider length of stay. Fewer hospital days means quicker patient recovery and lower cost for insurance companies. Therefore, surgeons applied a methodical, patient-specific approach that addresses their comorbidities, pain, nausea, hydration, bleeding risk, infection protection, mobilization, and complication prevention. Using pain control as one example, surgeon and anesthesiology teams came together to have patients take medication before the operation, undergo spinal anesthesia instead of general, receive local anesthetic in targeted spots during surgery, transition to less painful surgical techniques, and commit to a multimodal postoperative pain regimen – all while remaining cognizant of the opioid epidemic. Preliminary data from Dr. Claudette Lajam at NYU highlights that opioid prescriptions spiked when joint replacements were canceled during the early days of the pandemic, revealing the tradeoff between opioid dependency and arthritic patients without access. As a result of meticulously optimizing length of stay, time in the hospital was reduced from a matter of weeks to a matter of hours and inspired the recent emphasis on same day discharge surgery. In return, Medicare beneficiaries are now forced to pay more out-of-pocket ($185 Part B deductible and a 20% copay) for the very same outpatient joint replacements Medicare incentivized, downshifting the financial burden to patients themselves and exacerbating disparities.
  2. Consider safety. To prevent infection among other potential complications, we preoperatively check patients for nutrition status, swab noses for resistant bacterial strains, provide antibacterial wipes for patients to perform for decolonization before surgery, rarely insert a foley catheter to decrease the risk of introducing an infection, prep and drape the limb meticulously, and even sometimes wear space suits for additional cleanliness. When we refer patients to their primary care doctor or a specialist for medical optimization prior to joint replacement, it is not uncommon for patients to discover undiagnosed medical conditions warranting treatment during this process. We control the air, temperature, and personnel in the operating room, while also critically evaluating the instrumentation and implants for sterility before every operation. Like a pilot, we have a checklist to systematically verify the surgical site and procedure with the patient, their family, and team members for redundancy and maximum clarity.
  3. Consider the team. We have built several patient-centered clinical teams along all phases of care related to the hip or knee replacement episode. In the office, the surgeon or advanced practice provider engages in shared decision making and expectation management related to the procedure. The nurse or care coordinator clarifies logistics. A preoperative team medically optimizes the patient to ensure safety and also improve overall health and wellbeing. On the day of surgery, a pit crew of nurses, surgical technicians, trainees, advance practice providers, anesthesiologists, implant industry representatives, and the surgeon symphonically assemble to perform the surgery itself. Surgical processing sterilizes the equipment while environmental services clean the room to assist with throughput and cleanliness. Usually the same day, a physical therapist prioritizes this patient to encourage early movement and use of the new joint for rapid recovery and safety. Patient education is again reviewed by the nurse and case manager prior to discharge. Once home, the patient remains in close contact with the surgeon’s office for surveillance.
  4. Consider the technological advances. While conclusive long-term evidence is yet to be established for most breakthroughs, technology has changed the way we work to deliver a potentially better operation without resting on our laurels. As an example, surgeons worked with industry engineers to improve prostheses and have been able to increased durability of the implant up to 30 years or more. Robotic-arm assisted surgery with haptic feedback, as another example, represents a disruptive innovation and exciting new frontier in surgical precision and data aggregation potentially capable of revolutionizing how we approach the operation. Mobile applications and software platforms enable real time communication between patient and surgeon. Education material is available with a single click or tap. Telephone trees are a relic of the past.

Sometimes, you do get more than what you paid for.

Despite the story that the declining Medicare reimbursement pattern tells of our perceived value, orthopaedic surgeons and their teams continue to innovate novel workflows and processes to give patients a better and safer experience than ever before. Now, hip and knee replacement surgeons may no longer be able to continue choosing patients over practice survival. The callous but economic solution for surgeons would be to stop offering disease-eradicating joint replacements in favor of symptom-controlling injections for patients with certain insurance plans – not unlike the proposed strategy among specialists performing cardiac and eye surgery similarly undergoing devaluation.

Instead of deciding policy with the surgeons who trained their entire lives to care for patients, who are emotionally and financially invested in the outcome of their patients, and who get paid the same regardless of where the procedure is performed, insurance plans partner with for-profit hospital administrators. Unsurprisingly, all the financial risk has downshifted to surgeons and patients while hospital payments increased and insurance companies lined their pockets even in the midst of a pandemic. The trickle-down effect of entrusting “value-based care” to those who neither appreciate value nor actually render care has created a system that prioritizes profits over patients despite the best efforts of a medical team shackled by bureaucracy.

Unless we find a way to overcome our collective discomfort and lead the discussions related to our business, we lose the reigns in clinical medicine. And unless we disentangle the false narrative that our work is an easy, routine commodity from the reality that we habitually and collectively deliver life-altering excellence, we risk capitulating to a misaligned bureaucracy. Rather than treating “value-based care” as a smokescreen to protect profits, we must first align the practice and business of medicine to protect those who know the real value of our care and matter the most: the patient.


You can see the original article by Dr. Prem Ramkumar in Forbes Magazine Online:

If Patients Knew: Surgeon Stewardship Versus Balance Sheet Bureaucracy In Orthopaedic Surgery