In Wyoming, driving three hours in one direction is not necessarily considered extraordinary.
Charlie Robertson knows that firsthand. The longtime Wyoming resident and CEO of Casper (Wyo.) Orthopedics sometimes drives roughly three hours to Fort Collins, Colo., for something as ordinary as a Costco trip.
“Three hours one way and three hours back is not unheard of in the state of Wyoming for people,” Mr. Robertson told Becker’s.
That geography creates a different calculus for healthcare. Wyoming patients may not necessarily need to leave the state for most spine or orthopedic care, Mr. Robertson said. Orthopedics is relatively well represented, and he suspects the state’s number of spine surgeons per capita may be higher than outsiders expect.
But in a state with fewer than 600,000 residents spread across nearly 98,000 square miles, having a service somewhere is different from having it nearby.
For Casper Orthopedics, the challenge is therefore not simply recruiting more specialists. It is deciding which capabilities can be sustainably built close to patients, and ensuring the economics allow those physicians to remain there.
That equation is becoming harder. “You got to look at volume,” Mr. Robertson said. “Patient visits matter.” And as Medicare reimbursement pressure intensifies, he worries the consequences of getting that equation wrong will ultimately be measured in miles.
Rural access is about more than distance
The cost of traveling for orthopedic care is not confined to gasoline or time on the road.
Wyoming has a large industrial workforce, Mr. Robertson said, including people working in oil, extraction and transportation. An orthopedic or spine condition can therefore become an economic problem quickly.
“They got to get back to work because if they’re not working, they’re not earning money,” he said.
That has shaped how Casper Orthopedics thinks about specialty care. The independent practice traces its history to 1976 and is approaching its 50th anniversary. Its physicians span spine, joint replacement, sports medicine, trauma, hand, foot and ankle care, among other specialties.
But one of its more consequential expansions began outside the operating room. In 2019, Casper Orthopedics recruited Trevor Gessel, MD, its first physical medicine and rehabilitation physician. Until then, Mr. Robertson said, the organization had traditionally been an orthopedic surgical group.
Dr. Gessel brought nonsurgical services including injections, electrodiagnostic testing and ultrasound, along with training in sports and spine medicine. The addition helped Casper build something that Mr. Robertson believes is increasingly important to a comprehensive spine program: a pathway that does not begin with surgery.
Physical therapy, injections and other nonsurgical interventions allowed the practice to expand the options available before an operation became necessary. The model worked well enough that when Dr. Gessel wanted to shift more of his focus toward sports medicine, Casper began searching for another PM&R physician.
That search led the group to Trevor Mordhorst, MD, a Wyoming native whose practice focuses more heavily on neck and back conditions.
His connection to the state mattered. “He understands the distance people travel to get care,” Mr. Robertson said.
The rural specialty-care paradox
Building every possible service locally is neither realistic nor necessarily sustainable. That is one of the harder realities of practicing in a state with a small population.
Mr. Robertson said Casper’s physicians help identify gaps in care based on what they see in the community. The practice also drew on guidance from OrthoForum, an alliance representing 96 independent orthopedic practices and more than 4,100 physicians nationally, when it first explored adding PM&R. But ultimately, any new specialty has to clear a basic test: Are there enough patients to support it?
Mr. Robertson pointed to pediatric orthopedics and orthopedic oncology as examples of services the organization has discussed. The clinical need may exist, but an independent practice also has to determine whether there is enough volume to sustain a physician devoted to that work.
“Will there be enough work for that doctor, especially based on an independent practice model?” he said.
That creates a paradox for rural healthcare. A community can be too far from specialized care to make travel easy, yet too small to financially sustain every specialist closer to home.
Casper Orthopedics has to operate between those two realities. The practice expects joint replacement demand, for example, to continue growing as the population ages. Other highly specialized services may remain harder to support.
For Mr. Robertson, access therefore cannot be separated from economics. And Medicare reimbursement is making that connection increasingly difficult to ignore.
When a reimbursement cut becomes an access problem
Mr. Robertson’s concern about Medicare cuts is not abstract. For an independent practice serving a geographically dispersed population, he sees reimbursement pressure as a potential threat to the local availability of care.
OrthoForum has warned that CMS’ proposed 2027 Medicare Physician Fee Schedule could cut physician reimbursement for total hip and knee replacements by 20%. The group said the proposed reduction follows an 8% cut to Medicare reimbursement for orthopedic joint replacement surgeons that took effect in 2026.
For Casper Orthopedics, Mr. Robertson said those numbers are particularly concerning in a market where reimbursement is already strained.
“We’re looking at a 20% decrease in already low reimbursement rates,” he said. The concern is what happens when declining reimbursement collides with the fixed costs of delivering orthopedic care in a relatively low-volume market.
“Our patients are going to suffer if there’s not a doctor here that can do total joints,” he said.
That consequence looks different in Wyoming than it might in a dense metropolitan market. Losing access to a nearby service can mean traveling hours for care. Mr. Robertson believes that rural reality is insufficiently reflected in federal payment policy.
“I don’t think anybody in Washington, D.C., is thinking about how it affects a rural state like Wyoming,” he said.
The issue becomes more consequential as the population ages. Mr. Robertson said he is hearing renewed discussion around physicians reconsidering Medicare participation, a conversation he has heard before but believes is “trending up again.”
“When patients start hearing that, they get nervous,” he said. “What am I going to do about my total knee or my total hip?”
For a practice such as Casper Orthopedics, the question is not only what Medicare pays for a particular procedure. It is whether the broader economics remain strong enough to keep the physician, and the service, available in the community.
Independence has become a recruiting tool
There is another side to Casper Orthopedics’ rural equation. The geography that can make access difficult has increasingly become part of the practice’s recruiting pitch.
Mr. Robertson has worked at Casper Orthopedics for 25 years and has spent roughly 18 of them recruiting physicians. He said recruiting has become easier over the past five to 10 years. Years ago, a single viable candidate demanded extensive cultivation. Today, he sometimes finds himself sorting through multiple CVs.
Part of the change, he believes, reflects a group of physicians actively looking for something different from large health systems and major metropolitan markets.
“There is a fraction of surgeons who don’t want to be part of a hospital system,” he said. “They want to be an independent practice, and we want to defend our independence.”
Lifestyle matters, too. Mr. Robertson said some physicians are drawn to a smaller community where they can participate in local life and still have meaningful time with their families. He jokes that Casper may employ one of the few orthopedic surgeons who can routinely be found in the school pickup line at 3:30 p.m.
When recruiting a married physician, Mr. Robertson also pays close attention to whether the physician’s spouse can envision a life in Wyoming. A successful recruitment, in his experience, has to work for the family rather than just the surgeon.
“You see the patients at Walmart,” he said. His wife is a physical therapist, he added, and trips to the store can turn into impromptu conversations with people she has treated.
“People want that smaller town where they can make a difference, where they can integrate into the community and still have time for their family,” he said.
That pitch may become increasingly important as independent orthopedic practices compete with health systems for physicians. Casper cannot offer the scale or density of Chicago, New York or another major market. It can offer autonomy, community and the chance to build something patients might otherwise have to travel to find.
Building another path around insurance
Mr. Robertson does not believe the current reimbursement model can be Casper Orthopedics’ only path forward. The practice is increasingly focused on direct-to-employer arrangements, direct-to-consumer care, bundled pricing and cash-pay options.
The idea is straightforward: make the price of care clearer and create pathways that reduce reliance on traditional insurance intermediaries. Mr. Robertson has spent roughly 35 years in healthcare, and he said the financial pressure has become increasingly difficult to reconcile.
Patients are struggling with affordability. Physician reimbursement is under pressure. At the same time, the practice’s underlying expenses, from implants to employees, have not disappeared.
“There’s got to be a way that we bypass insurance companies, go directly to patients and employers and say, ‘Hey, this is what it costs,’” he said.
For Casper Orthopedics, those models are more than a reimbursement experiment. They are part of a larger effort to preserve independence and keep care viable in a market where losing local access can mean traveling hours.
The question facing the practice is not whether every orthopedic service can be built close to home. It is how much can be, and whether the economics will allow it to stay there.
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