The question facing orthopedics in 2026 is no longer whether the specialty can innovate, but whether it can sustain that innovation.
Rising costs, staffing shortages and continued reimbursement pressure are forcing practices to more closely examine how care is delivered, and whether it provides enough value to justify its cost.
Ronald Gardner, MD, an orthopedic and sports medicine physician who leads Gardner Orthopedics in Fort Myers, Fla., believes those pressures are accelerating a long-overdue shift toward outcomes-based decision-making. In his view, the system has reached a point where interventions must be more deliberately tied to measurable benefit.
“I think that we’ve reached a point where it’s going to be critical for us to do research, which will eventually lead to the application of almost exclusively value-based and outcomes-based medicine,” Dr. Gardner said.
While technological advances have expanded what orthopedics can do, he said the system’s resources have not kept pace. As a result, the specialty must begin scrutinizing not just how procedures are performed, but whether they should be performed at all.
“We just can’t be doing multi, $10,000-plus procedures that are going to potentially be redone again in the distant future, or that aren’t getting really good value-based results,” he said.
Rethinking intervention across musculoskeletal care
Dr. Gardner believes orthopedics is only beginning to seriously examine whether less invasive or nonoperative approaches can deliver outcomes comparable to surgery for certain patient populations. Osteoarthritis, which represents a large share of his practice, is a prime example.
If patients can achieve similar functional outcomes through conservative care, even temporarily, delaying surgery could reduce overall cost and lower the risk of revision procedures later in life.
“If you get similar results from the nonoperative care of osteoarthritis as you do from the operative care, and maybe delay surgical procedures for five or 10 years, then you can certainly get to a position where it’s cost-effective,” Dr. Gardner said.
He sees the same logic applying to spine care, where minimally invasive procedures, physical therapy and noninvasive treatments may offer meaningful benefit without escalating cost or risk.
“I think that we can probably save the system without jeopardizing quality of care,” he said. “I think that we can save the system billions and billions of dollars a year, and at the same time not sacrifice quality of care.”
Historically, Dr. Gardner noted, research has not been oriented toward identifying when fewer interventions can deliver equivalent outcomes. But growing financial pressure is making that question unavoidable, particularly in the U.S., where similar models have been slower to develop than in parts of Europe.
Reimbursement pressure and the erosion of revenue
At the practice level, reimbursement remains a central concern. While payment cuts are familiar to most orthopedic leaders, Dr. Gardner emphasized that some of the most significant reductions occur quietly through changes to relative value units.
“You don’t realize that you’re getting the cut until you realize that they cut the RVUs for it,” he said.
When RVU reductions coincide with lower per-unit payment, the financial impact can be substantial. That pressure is intensified by persistently high operating costs following years of inflation.
“Our labor costs are way up, our product costs are way up, but our production revenue cycles are down per unit of work,” Dr. Gardner said. “Those lines are going to cross in the not-too-distant future unless we do some things getting back to value-based medicine.”
He believes value-based approaches may be one of the few paths forward that protect both patients and practices, ensuring healthcare dollars are used more prudently without compromising outcomes.
Policy uncertainty and patient access
Dr. Gardner is also closely watching federal policy discussions, including proposals that could affect Affordable Care Act subsidies. While the downstream impact on orthopedics remains uncertain, he expects some patients could be left with fewer or more complex coverage options.
Still, he has been surprised by how engaged patients are in these discussions.
“I have had patients who said, ‘Heck, if we can send that money to me and I can use it to supplement my healthcare policies, I think I can provide myself a better plan,’” he said.
Those conversations, he noted, reflect growing skepticism about how healthcare dollars are currently distributed, particularly when subsidies flow to insurers rather than directly supporting patient choice.
Staffing shortages and administrative burden intensify
Operational challenges continue to mount, particularly around staffing. Dr. Gardner described a dramatic shift in applicant availability over the past several years.
Six years ago, a single job posting could generate dozens of qualified candidates within days. Today, similar postings may yield only one or two applicants over the course of a week or longer.
“We may run an ad for a week and get two qualified applicants,” he said.
Whether driven by workforce shortages, shifting expectations or competition within local markets, staffing qualified positions at sustainable wages has become increasingly difficult, especially for independent practices.
That challenge is compounded by expanding administrative requirements. Prior authorizations, insurance verification, coding oversight and documentation demands now touch nearly every patient encounter.
“There’s more paperwork, more authorizations, more hoops to jump through for virtually every procedure that we do,” Dr. Gardner said.
Treating the patient, not just the joint
Despite mounting pressures, Dr. Gardner remains committed to individualized, context-driven care. In his practice, treatment decisions are shaped not only by imaging and diagnosis but by patients’ personal circumstances and responsibilities.
In some cases, that means accelerating surgery so a patient can care for a spouse. In others, it means postponing surgery for months or years while conservative treatments keep patients comfortable during major life events.
As he put it, “we don’t treat the X-rays, we treat the patient.”
That approach, he said, requires having multiple treatment options available so care can be customized to the whole person, not just the condition.
A caution on technology dependence
While technological innovation continues to reshape orthopedics, Dr. Gardner expressed concern about growing dependence on robotics, imaging and AI, particularly in training environments.
He has observed younger physicians becoming increasingly reliant on technology, sometimes at the expense of foundational skills.
“If a robot goes down or malfunctions, we want to make sure that our people are fundamentally trained,” he said.
In his view, returning to fundamentals, sound clinical judgment, adaptability and attentive listening, will be essential as orthopedics navigates a more complex and constrained future.
As 2026 approaches, Dr. Gardner sees both urgency and opportunity. Financial pressure, policy uncertainty and operational strain are forcing orthopedics to reexamine long-standing assumptions about care delivery.
For practices willing to focus on value, outcomes and fundamentals, he believes the specialty can move toward a more sustainable future, one that protects both patients and the systems that care for them.
