Douglas Padgett, MD, surgeon-in-chief and chair of orthopedics at New York City-based Hospital for Special Surgery, has built his career at the intersection of surgical innovation, education and patient-centered care — a balance he continues to refine as the field evolves.
Now, he said, orthopedics is facing one of its most turbulent chapters — a time when financial and operational pressures are converging in ways few could have anticipated.
“From payer pressures to the migration of joint replacement from inpatient to outpatient, the squeeze is real,” Dr. Padgett told Becker’s. “We’re all being asked to deliver the same — if not more — with less.”
He pointed to several sources of strain, including a 7% reduction in joint replacement reimbursement expected to take effect Jan. 1 if nothing changes. That financial hit, he said, is compounded by the broader shift of procedures to outpatient settings and by the loss of National Institutes of Health funding many academic centers once depended on.
Still, Dr. Padgett sees opportunity within that strain.
“Behind any real challenge is opportunity,” he said. “I wouldn’t go so far as to call it a crisis, but it’s absolutely a difficult moment. It’s also a moment for big organizations to step back and ask, ‘How are we delivering care, and is it time to think differently about how healthcare is managed?’”
For orthopedics, he believes that means rethinking the traditional one-on-one model of care — a system he said may not be sustainable as volumes grow and resources shrink.
“Looking into the ability to manage those episodes of care in either a remote setting or some other setting — does this involve the use of agentic AI? Perhaps. I think there’s a definite role for that,” he said.
That approach, Dr. Padgett added, could help move the field beyond its narrow focus on the “last 5%” of the patient journey — the surgical endpoint — and toward upstream disease management.
The goal, he said, is to use new tools — from remote monitoring to AI-enabled guidance — to help patients earlier in that continuum while maintaining quality and access.
“There’s going to be some investment up front,” he said. “I think in the long run it will help, and it may help the financial future of organizations and institutions.”
At the same time, he voiced concern that these innovations could be undermined by constant reimbursement pressure.
“Every time we figure out a way to do things better,” he said, “the depressing part is that payers — in the form of CMS or others — continue to put further downward pressure on it, and it always becomes the proverbial race to the bottom.”
Beyond system-level challenges, Dr. Padgett is thinking deeply about how to prepare the next generation of orthopedic surgeons for a healthcare environment that looks very different from the one he entered.
“The healthcare system they’re entering looks very different from the one I trained in,” he said. “They need to understand the element of being smart. You never want to compromise the quality of care, but you need to be mindful of the costs associated with it.”
At HSS, he encourages trainees to evaluate technology critically — to think beyond hype and focus on measurable value.
“We have every single enabling technology that you could possibly want,” he said. “But we need to be more deliberate in terms of honest evaluation — constantly looking at the value proposition as it relates to what we do.”
That rigor, he said, helps physicians distinguish true progress from novelty.
“I’m not a Luddite; I’m not trying to stifle innovation,” he said. “But at some point, is it delivering? And it needs to be more than, ‘I use it because it’s fun.’ Unfortunately, in some instances, that’s why it’s being used — and I’m not sure that’s a compelling reason.”
When asked how he defines value in orthopedics, Dr. Padgett was succinct.
“The equation is simple, but it’s the definition of the variables that will go,” he said. “Value is quality over cost. That quality measure means there’s a variety of things that you can put in the numerator. For me, there has to be measurable quality improvement, outcome measures, reductions in complications — all of those things are what I specifically look at.”
He said new technology should be assessed through that same lens — whether it demonstrably improves patient outcomes or merely adds cost.
“The vendors are no joke when it comes to that,” he said. “They can link a lot of the technology with devices, implants and the like. What happens is they sell them as a package, but ultimately it drives up the entire episode of care. Are the outcomes measurably better? To be determined.”
That’s why HSS has created a structured process for evaluating emerging technologies — a committee composed of physicians who assess new innovations for safety, cost and clinical impact.
“We have a committee of physicians who are on our civic technology evaluation platform, and they are very strident in their approach toward this,” he said.
Despite the turbulence, Dr. Padgett remains optimistic about the field’s direction.
“We’re in good financial shape here at the organization,” he said. “But it’s a constant, iterative process of looking at procedures, policies and processes in terms of how we deliver care. It’s got to be second to none. Patient safety has to be the highest quality.”
