Alexander Vaccaro, MD, PhD, has spent decades inside operating rooms, lecture halls and executive meetings. As 2026 approaches, his focus is shifting toward who will shape what orthopedics becomes.
As professor and chair of orthopedic surgery at Thomas Jefferson University and president of Rothman Orthopaedics in Philadelphia, Dr. Vaccaro occupies a rare vantage point. He sees the specialty from nearly every angle: academic, entrepreneurial, clinical and operational. And from that position, he sees a field under mounting pressure.
“There’s a battle for top-notch orthopedic providers,” he said. “That battle is between private practice, multispecialty groups, hospital systems and private equity.”
For Dr. Vaccaro, that competition is not simply about recruiting surgeons. It reflects a broader struggle over control of care delivery, innovation and the future role of physicians themselves.
The quiet cost of “risk-free” medicine
Dr. Vaccaro is candid about what he sees as the central tension facing orthopedics: stability versus autonomy.
“If you join a healthcare system today, you basically join a risk-free compensation model,” he said. “The more [relative value units] you generate, the more you get paid. And I’m not sure that’s in the best interest of the patient or the physician.”
In employed models, predictability can come at the expense of flexibility. Decision-making shifts away from physicians, incentives narrow and opportunities to innovate diminish. At Rothman, Dr. Vaccaro said the goal has been to preserve an alternative, one built around ownership, accountability and choice.
“We try to give doctors the opportunity to be innovative in the care they provide, to have the flexibility and autonomy they need,” he said. “That’s what represents private practice.”
Ownership as strategy, not reward
For Dr. Vaccaro, ownership is not about wealth accumulation. It is about alignment.
Outside of hospital employment, he said surgeons can hold ownership stakes in ASCs, specialty hospitals and ancillary services, not to inflate costs, but to control them. Ownership allows physicians to design care pathways intentionally rather than reactively.
“There are so many creative, productive ancillary lines,” he said. “These are things the employed model really does not allow individual surgeons to reap the rewards of or be incentivized by.”
That philosophy extends to staffing. Dr. Vaccaro believes every member of the care team should work at the top of their license, from surgeons to physician assistants and support staff.
“If you’re licensed to do certain things, you should be doing those things,” he said. “You shouldn’t be relegated to a role below your training.”
Efficiency, he added, is not about pushing clinicians harder. It is about removing friction so people can focus on what they are trained to do.
Technology, stripped of hype
Dr. Vaccaro is not interested in technology for its own sake. But he is deeply invested in what technology can eliminate: inefficiency, imprecision and administrative burden.
“I hate to say the buzzword agentic AI,” he said, “but I use it multiple times every day.”
At Rothman, advanced tools are already embedded across the practice, from robotics in the operating room to AI-supported workflows that manage insurance denials, appeals and scheduling. These tools, he said, make surgery safer and more reproducible, while also helping practices withstand growing administrative demands.
“We’re using advanced technologies to make surgery safer, more accurate, more precise,” Dr. Vaccaro said. “But also to respond immediately when cases are denied, to appeal, to keep offices full and to maximize staff.”
For him, technology is not about replacing clinicians. It is about supporting them.
The headwinds against the system
Even with innovation, the pressures on orthopedic practices continue to intensify.
“The biggest problem we have as providers is dealing with prior authorization,” Dr. Vaccaro said, pointing to decisions made by individuals far removed from patient care. “They abide by clinical practice guidelines that don’t take into consideration individual patients.”
Those denials, combined with downcoding, shifting policies and shrinking reimbursement, create a system that asks physicians to do more with less each year.
“Every day, my overhead costs go up,” he said. “Staffing, salaries, inflation, cost of capital. And reimbursement goes down. It doesn’t make any sense.”
The result, he warned, is a system increasingly misaligned with patient needs and difficult for providers to sustain.
Reimagining how patients move through care
Clinically, Dr. Vaccaro believes the next meaningful shift in orthopedics will come from rethinking the patient journey and reducing friction wherever possible.
“If it’s something you have to prescribe to a patient, why can’t we be the owner of that business?” he asked, describing in-house approaches to braces, injections and nonoperative care.
Ownership, he said, allows physicians to lower costs while maintaining quality.
He also sees promise in concierge-style musculoskeletal care, not as a replacement for traditional models, but as an option for patients seeking fewer barriers.
“Why can’t we make that easy for MSK care?” he said. “Organize imaging, therapy, injections, surgery and support patients and their families through the entire journey.”
Dr. Vaccaro emphasized that all patients should receive the same quality of care, even if some have the ability to pay for less frustration in navigating that care.
Scaling through people, not volume
As practices grow geographically, Dr. Vaccaro sees physician assistants as essential to sustainability and access. They are often the first point of contact for patients and play a critical role in determining when higher-level care is needed.
“They interface with our patients. They see patients in clinic. They select those that may need higher-level care,” he said.
At Rothman, workforce planning is data-driven, tracking wait times, visit demand and care complexity to determine when additional clinicians are needed.
“It helps us build our workforce appropriately,” Dr. Vaccaro said. “And it helps us support professional growth.”
Culture over consolidation
Growth, Dr. Vaccaro insists, cannot come at the expense of identity.
“Culture trumps strategy any day of the week,” he said.
Rothman’s expansion has focused on organic growth and alignment, investing in physicians trained within the system and partnering with groups that share its values around clinical excellence, education and research.
“We want to team up with like-minded people,” he said. “But leave economies local.”
Technology, he added, makes that balance possible by enabling scale without sacrificing autonomy.
The lesson that reshaped his thinking
Looking back at 2025, Dr. Vaccaro said the issue that most reshaped his perspective was not reimbursement or technology, but risk.
“The ‘nuclear’ verdicts are a huge problem,” he said, referring to malpractice awards in cases involving competent, not negligent, care.
Unchecked legal exposure, he warned, threatens not only individual physicians, but entire communities that lose access when practices close.
“If you do everything right and still face a verdict that shuts you down,” he said, “that affects every patient who depends on that care.”
He also pointed to cybersecurity as a growing threat, describing ransomware attacks that can cripple health systems overnight.
“[Cybercriminals] are sophisticated,” he said. “They use AI-generated strategies. And suddenly you’re locked out and have to pay the price.”
A future that demands protection — and leadership
For Dr. Vaccaro, the future of orthopedics will not be defined by a single innovation or policy. It will hinge on whether physicians retain the ability to lead.
“We were decimated as a profession during COVID while we gave our time and our lives to take care of patients,” he said. “We need the federal government to step in and help protect those who care for people.”
As 2026 approaches, he sees a specialty facing difficult choices, but also clear imperatives: autonomy, accountability, technology with purpose and leadership willing to fight for all three.
