Orthopedic surgeons have spent years figuring out how to send patients home sooner, reduce complications and make joint replacement more efficient. Now, some are confronting an uncomfortable paradox: The better they become at delivering care, the harder it may be to sustain the infrastructure behind it.
For Ravi Bashyal, MD, director of outpatient hip and knee replacement surgery at Evanston, Ill.-based Endeavor Health, the tension has become impossible to ignore.
His team has spent roughly a decade developing an outpatient joint replacement program that began at Endeavor Health Skokie (Ill.) Hospital and is now expanding across a much larger health system. Patients who once spent days recovering in the hospital can increasingly return home the same day.
But the work hasn’t disappeared. Much of it has simply moved out of sight.
“A shorter hospital stay doesn’t mean less care,” Dr. Bashyal told Becker’s. “In fact, it means more preparation ahead of time and more team coordination.”
That distinction is becoming increasingly consequential as Medicare reimbursement cuts collide with rising operating costs and growing demand for joint replacement.
The price of doing more with less
CMS’ final 2027 Medicare Physician Fee Schedule was a major topic at the recent American Association of Hip and Knee Surgeons meeting in Dallas, Dr. Bashyal said.
For surgeons already managing rising salaries, staffing expenses and practice overhead, additional reimbursement pressure raises questions about how long existing care models can remain sustainable. The challenge is particularly acute for independent practices, which have fewer resources to absorb declining payments.
“We’ve gotten a lot better at doing joint replacement in general,” Dr. Bashyal said. “Complication rates are lower than they’ve ever been, at least many of them are. Outcomes are great. Patients are doing really well, but it’s odd to almost feel punished for doing that.”
The frustration reflects a disconnect between how efficiency is measured and how care is actually delivered. Same-day discharge eliminates a hospital overnight stay, but it requires careful patient selection, preoperative preparation and coordination among anesthesia, nursing, physical therapy and pharmacy teams. After discharge, patients still need clinical guidance, monitoring and access to support.
“Just because the patient’s going home the same day doesn’t mean that there was less work involved,” he said.
Dr. Bashyal argues that the resources required to achieve a successful outpatient recovery deserve greater consideration in payment and performance models.
Otherwise, he worries, continued reimbursement reductions could eventually affect the staffing and support systems that make high-quality care possible. The consequences may extend beyond surgeons’ balance sheets.
“I foresee issues with patient access, availability and wait times,” he said. “And I don’t want us to go there.”
Scaling a decade of work
Despite those concerns, Dr. Bashyal sees significant opportunities for orthopedic growth over the next several years. At Endeavor Health, one priority is expanding the outpatient joint replacement model developed at Skokie Hospital across the system’s broader network.
The program began as NorthShore University HealthSystem, which was a four-hospital system. Endeavor’s expanded footprint now offers opportunities to bring established practices to additional facilities, while a proposed merger with Chicago-based Rush University System for Health could create further possibilities if completed.
For Dr. Bashyal, the opportunity is not simply to perform more operations. It is to scale the coordination and expertise that make outpatient surgery successful. That means sharing lessons among clinical teams, learning from colleagues who have developed similar programs and ensuring that growth does not come at the expense of patient outcomes.
The need is there, he said, as demand for hip and knee replacements continues to increase. But expansion will require investment in the same personnel and processes facing mounting financial pressure.
Beyond the operating room
Dr. Bashyal believes the next opportunity for orthopedic programs may also lie in rethinking how patients access specialty care.
Through Endeavor Health’s partnership with the National Basketball Retired Players Association, where he serves as chief medical officer, he has helped develop a model that brings multiple specialties together for former professional athletes.
Rather than navigating separate appointments across several weeks, patients traveling from other states can undergo imaging, consultations and other evaluations during a coordinated one- or two-day visit.
A former player might receive a spine MRI, hip imaging and consultations with orthopedic, neurological and cardiovascular specialists in a single trip.
The arrangement can seem counterintuitive. Why travel across the country for care that may be available closer to home?
Dr. Bashyal said the answer is coordination. By consolidating services, the program can reduce the time patients spend scheduling appointments, traveling between providers and managing fragmented care. The model also illustrates a broader growth opportunity for orthopedic programs: Building relationships that encompass education, navigation and access to specialists, rather than focusing exclusively on surgical referrals.
Building something that lasts
Dr. Bashyal’s emphasis on sustainable care extends to Nepal, where he works with Operation Walk Chicago, a nonprofit that provides free hip and knee replacements to underserved patients worldwide while training local surgical teams.
Through its longstanding partnership with Nepal Orthopaedic Hospital in Kathmandu, the organization has focused on building local expertise rather than simply performing surgeries during medical missions.
Dr. Bashyal credits co-founder David Stulberg, MD, with helping establish a model that has transformed the hospital from a relatively low-volume center into one of Nepal’s leading joint replacement providers. The effort relies on volunteer clinicians, donors and medical device companies that contribute implants and supplies.
For Dr. Bashyal, the experience reinforces a lesson equally relevant to outpatient surgery in the U.S.: Sustainable growth requires more than successful operations.
As health systems pursue shorter hospital stays and greater surgical volumes, he believes they must recognize the people, resources and coordination behind those gains. Less time in the hospital, he argues, does not necessarily mean less care.
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.
