Orthopedic care is approaching a potential access problem as demand rises while the number of surgeons available to treat patients declines.
At the same time, reimbursement pressure, growing administrative burdens and payer restrictions are making some practices reconsider which patients they can afford to treat.
Here are five forces putting pressure on orthopedic access:
1. The orthopedic workforce is shrinking: The number of orthopedic surgeons in the U.S. has declined in recent years even as an aging population drives greater demand for musculoskeletal care.
There were about 14,100 orthopedic surgeons practicing in 2025, down from 16,260 in 2021, according to Bureau of Labor Statistics data. That represents a decline of more than 13% in four years.
The workforce trend has raised concerns about whether practices will have enough surgeons to meet future demand. Orthopedic leaders have said continued declines could mean longer wait times, greater reliance on advanced practice providers and increased pressure on remaining surgeons.
The challenge is magnified by demographics. The population of older Americans, who account for a significant share of joint replacements and other orthopedic procedures, continues to grow as the surgeon workforce contracts.
2. Medicare participation is becoming harder for some practices to justify: Independent orthopedic groups are also reconsidering the economics of treating Medicare patients.
Inflation-adjusted Medicare physician payment has declined 33% since 2001, while practice expenses including labor, malpractice coverage, technology and supplies have continued to rise.
The American Alliance of Orthopaedic Executives, which represents more than 1,300 members across 660 practices, warned Congress in May that the widening gap is contributing to consolidation, hospital employment and practices limiting Medicare patients.
The trend has already emerged in some markets. AAOE cited orthopedic practices that have stopped accepting new Medicare patients or withdrawn from Medicare altogether as financial pressures mounted.
3. Joint replacement reimbursement faces another potential hit: The pressure could intensify in 2027.
CMS’ proposed Medicare Physician Fee Schedule could reduce physician reimbursement for total hip and knee replacements by about 20%, according to the OrthoForum, an alliance representing 96 independent orthopedic practices and more than 4,100 physicians.
The proposed reduction would affect CPT codes 27130 and 27447 for total hip and total knee replacements. It follows an 8% Medicare reimbursement reduction for orthopedic joint replacement surgeons that took effect in 2026, according to the organization.
The OrthoForum has warned that another substantial reduction could put additional pressure on independent practices and affect Medicare beneficiaries’ access to musculoskeletal care.
The concern is particularly significant because Medicare patients account for a substantial share of the joint replacement population.
4. Prior authorization is delaying patients who do have access to surgeons: Having enough surgeons is only one component of access. Patients must also be able to get recommended care approved.
Orthopedic and spine leaders have identified prior authorization and rigid payer coverage policies as major barriers to timely treatment.
Surgeons have described algorithm-driven reviews, requirements that fail to account for clinical nuance and denials from reviewers without relevant specialty expertise. The result can be weeks or months of delays for procedures physicians consider medically necessary.
CMS has also expanded prior authorization into additional musculoskeletal services through its Wasteful and Inappropriate Service Reduction model. The six-year model includes 17 services identified by CMS as potentially vulnerable to overuse, including cervical spinal fusion, epidural steroid injections, vertebral augmentation and image-guided lumbar decompression.
Meanwhile, higher deductibles and out-of-pocket costs can create another barrier, contributing to delayed or canceled procedures even after patients receive clinical approval.
5. The hardest cases could become the hardest to access: Reimbursement pressure may disproportionately affect patients who require complex care.
Orthopedic leaders have argued that the current Medicare structure does not always account for differences in case complexity. A relatively healthy patient and one with diabetes, osteoporosis, obesity or other significant comorbidities can fall under the same procedure code despite requiring different levels of operative time, postoperative management and resources.
That creates a potential financial disincentive for surgeons and organizations taking on the most difficult cases.
Michael Gross, MD, orthopedic director of Union Middlesex Orthopedics in Woodbridge, N.J., has argued that Medicare should reimburse surgeons based more closely on patient and case complexity.
Similar concerns are emerging in arthroplasty. Jay Lieberman, MD, chair of orthopedic surgery at Los Angeles-based Keck School of Medicine of the University of Southern California and director of USC Orthopaedic Surgery at Keck Medicine of USC, has warned that the economics could eventually reach a point where surgeons decide they can no longer perform certain Medicare cases.
“I think at some point surgeons will say, ‘I just can’t do these cases,’” he said. “And the problem is, the patient’s going to suffer because then there’s going to be an access issue.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
