Joint replacement has spent decades becoming more efficient. Patients who once stayed in the hospital for days can increasingly go home the same day or the next. Surgeons optimize medical risks before the procedure, coordinate care across specialties and continue monitoring patients after they leave the hospital.
Antonia Chen, MD, sees a problem in that progress. The work required to deliver a successful joint replacement has not necessarily disappeared as hospital stays have shortened. It has moved.
And Dr. Chen, president of the American Association of Hip and Knee Surgeons and chair of orthopedic surgery at UT Southwestern Medical Center in Dallas, believes the Medicare payment system is struggling to see where it went.
That tension has become urgent as hip and knee surgeons push back against a proposed 20% reduction in CMS payment for total joint replacement in 2027. The cut is included in CMS’ 2027 Medicare Physician Fee Schedule proposal, released July 14. The agency is accepting comments through Sept. 14 and is expected to finalize the rule later this year.
It follows an 8% cut to Medicare reimbursement for orthopedic joint replacement surgeons that took effect in 2026, making this the second consecutive year of reductions to hip and knee arthroplasty payment.
For Dr. Chen, the fight is about more than one cut. It is about what Medicare considers physician work in an era when better care increasingly happens outside the most visible parts of an episode.
“The problem is everything is valued by time, and no one actually sees the time unless I bill it,” she told Becker’s.
The hospital stay shrank. The work moved.
Dr. Chen points to the evolution of joint replacement itself. Thirty years ago, a patient undergoing hip or knee replacement could remain hospitalized for an extended period. Surgeons saw those patients repeatedly after surgery, making that work easy to observe and count.
Modern arthroplasty looks very different. Same-day and next-day discharge require surgeons to do more before the operation.
Patients with obesity, diabetes, smoking histories, heart conditions or other risks may need weeks or months of optimization. Surgeons coordinate with specialists, monitor progress and make sure patients are medically prepared to recover safely outside the hospital.
Then the patient goes home. The work continues through phone calls, portal messages and follow-up that may never appear as a separately billed encounter.
“I do a lot more work now than I did in the past,” Dr. Chen said. “We’re spending a lot more time on the front side optimizing our patients.”
The irony, in her view, is that the efficiency those efforts create can make the episode look easier. A shorter hospital stay reduces visible postoperative physician time. But it may exist precisely because more work occurred before the patient ever reached the operating room.
That is the disconnect Dr. Chen wants policymakers to understand.
Efficiency can become its own penalty
The same contradiction extends beyond individual cases. Hip and knee surgeons have helped push arthroplasty toward shorter stays, outpatient settings and bundled payment models designed to reward better outcomes at lower total cost.
Dr. Chen supports that direction. What concerns her is an incentive structure that asks surgeons to keep driving those savings while reducing their individual payment.
“The hard part is they’re cutting just the surgeon fee, but the hospital is getting the benefit for the bundle payments,” she said.
That matters because surgeons influence many of the variables that determine whether a joint replacement episode succeeds. They decide when a patient is ready for surgery. They drive clinical pathways. They encourage patients to complete outcome surveys. Their decisions affect length of stay, complications, readmissions and recovery.
Yet under some value-based arrangements, Dr. Chen said the savings flow primarily to the hospital. If physician reimbursement is reduced at the same time, she worries the model begins asking surgeons to take on more responsibility with less reason to participate.
“The short answer is, it’s not going to be maintainable,” she said. “If you cut it, then why am I going to put all this work into saving the bundle money?”
Her argument is not against value-based care. It is that value-based care becomes harder to sustain when the clinician driving much of the episode is economically disconnected from the value being created.
The first pressure point may be access
Dr. Chen believes patients will feel that misalignment before policymakers do. She worries some surgeons will respond to continued payment pressure by limiting Medicare patients or leaving Medicare altogether.
“The biggest problem is that it’s going to hurt our seniors or anyone with Medicare,” she said.
For patients, that does not necessarily mean joint replacement disappears. It may mean waiting longer for it. That distinction matters because osteoarthritis does not remain static while a patient waits.
Dr. Chen regularly hears a version of the same comment from patients after surgery: I wish I had done this sooner.
She worries the system could increasingly force patients in the opposite direction. A patient who is already struggling to walk may decline further. Activity can decrease. Pain can intensify. Someone who was limping may eventually require a wheelchair.
“Patients may want to have surgery sooner, but they may not be able to,” she said. “I just can’t get them in because of the limitations the system places on us.”
For an aging Medicare population, the consequence of delayed joint replacement is therefore not limited to the joint. Mobility affects the rest of a patient’s health. That is why Dr. Chen objects to viewing arthroplasty simply as another expense to reduce.
A successful joint replacement can restore a patient’s ability to move. Delay can allow the opposite to happen.
The other response is more volume
There is another way surgeons could absorb lower reimbursement. Do more surgery. That possibility worries Dr. Chen almost as much as declining Medicare participation.
“If I normally do six to seven in a day, and now I’m doing 12 or 13 to make up for that 20%, well, the quality is just not going to be as good,” she said.
The numbers were illustrative, but the tension is real. If reimbursement falls far enough, practices have only so many levers. They can reduce expenses. Limit certain patients. Leave insurance networks. Or increase volume.
Dr. Chen believes payment policy should not push surgeons toward a choice between maintaining access and protecting the time required for high-quality care.
Instead, she wants Medicare to directly reward both. Her preferred model would give surgeons meaningful incentives for maintaining patient access, meeting quality benchmarks and producing good outcomes, rather than placing much of the value-based reward with the facility while separately cutting the physician fee.
“If we want to do this, we have to incentivize the person who’s doing the work,” she said.
Hospitals still belong in that model. Joint replacement depends on the surgeon and facility working together. Dr. Chen’s point is that their incentives should move together, too. A system in which hospital economics improve while surgeon economics deteriorate creates tension inside the same episode of care.
AAHKS is fighting for more than a reversal
AAHKS’ immediate priority is stopping the proposed cut. The organization is submitting comments to CMS, encouraging surgeons to contact congressional representatives and giving patients and orthopedic team members ways to make their concerns known.
Dr. Chen said AAHKS also plans to meet directly with congressional leaders when they return from the August recess, with additional meetings with CMS and federal policymakers expected as the rulemaking process continues.
It has also formed a task force involving current and former association leaders to coordinate its response.
But Dr. Chen sees the 2027 proposal as a symptom of a larger problem. “The hardest part here is honestly the fact that we haven’t had a seat at the table determining how valuation happens,” she said.
She wants AAHKS and other orthopedic stakeholders more directly involved in determining how contemporary arthroplasty work is measured. The long-term goal is not simply to argue against cuts each time they appear. It is to change the process that produces them.
Dr. Chen wants CMS, physician organizations and other stakeholders to sit down together and determine what the modern joint replacement episode actually requires. That means examining what happens before surgery, in the operating room and after discharge, rather than treating shorter hospitalization as evidence that physician work has simply vanished.
AAHKS is asking CMS to pause the proposed reduction while that valuation is reconsidered.
“We want to sit at the table to talk about where we can work together as a big collaborative group,” Dr. Chen said.
The bigger question is what Medicare wants to reward
Dr. Chen does not want joint replacement to return to the way it was 30 years ago.
She wants the opposite. Keep patients healthier before surgery. Keep improving outcomes. Keep shortening unnecessary hospital stays. Keep moving appropriate procedures into lower-cost settings. Keep developing payment models that reward quality instead of volume.
But those goals create a fundamental question for Medicare. If surgeons become more efficient, should the payment system conclude that they are doing less? Or should it ask what work made that efficiency possible?
Modern arthroplasty has moved significant portions of the episode beyond the hospital room. Dr. Chen believes reimbursement has to follow that evolution.
Otherwise, the system risks creating a strange reward for progress: The better surgeons become at making joint replacement efficient, the less their work appears to be worth. And eventually, she argues, patients will absorb the difference.
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