The modern orthopedic surgeon does not practice in a vacuum of anatomy and biomechanics. They practice inside a system of reimbursement formulas, employer contracts, regulatory mandates and evolving payment models.
Yet most are never formally taught how that system works.
When Benjamin Schwartz, MD, chief medical officer at Marina Del Rey, Calif.-based Commons Clinic, was asked to present a webinar on the U.S. health insurance system to orthopedic residents, he was allotted just 10 minutes.
“Ten minutes is barely enough time to explain co-pays let alone provide a working understanding of the system,” he wrote in a LinkedIn post.
For Dr. Schwartz, the time constraint underscored a broader problem: business education in medicine remains optional, even as it becomes indispensable.
Orthopedics at the center of payment reform
Orthopedics has become one of the most scrutinized specialties in American healthcare, not because of its outcomes, but because of its cost footprint.
“For orthopedics, specifically, we’ve sort of been the proverbial tip of the spear when it comes to all of these reforms of payment,” Dr. Schwartz told Becker’s, pointing to CMS’ focus on joint replacement and spine surgery.
Musculoskeletal care has also become a major target for employers, he added, as organizations look more closely at the conditions driving healthcare spending.
“It’s not the governmental payers,” he said. “It’s also employers and commercial insurance companies.”
The result is that orthopedics is being reshaped by forces many surgeons never formally study, despite being directly affected by them.
The education gap no longer works
Dr. Schwartz believes one reason these topics remain secondary is structural: most physicians train in academic environments, insulated from the operational realities that dominate practice. “We’re insulated from that stuff when you’re a resident or a fellow,” he said. “You don’t really see that part of it.”
Then, suddenly, it becomes unavoidable. “It’s a shock when you’re out in practice,” he said, “and then you realize that it’s a big part of what you do.”
Another barrier, he noted, is cultural. For decades, the business of healthcare has been treated as uncomfortable territory in medical training, something adjacent to medicine, rather than embedded within it. “It’s been a little bit taboo,” he said, “because it just seems that shouldn’t be the focus.”
But the system does not allow physicians to opt out of its economics. “You have to stay on top of things if you want to survive,” Dr. Schwartz said.
A system too complex to ignore
Even for physicians who actively seek out business expertise, the learning curve is steep.
Dr. Schwartz, who has spent 17 years working within the healthcare system across multiple leadership and management settings, said preparing for his resident talk only reinforced how much remains opaque.
“We see patients, we bill a code and stuff happens behind the scenes,” he said. “The payment shows up or doesn’t show up.”
To adapt, physicians must first understand what they do not yet see. “It’s kind of like you don’t know what you don’t know,” Dr. Schwartz said. “The first step is learning what you don’t know, and then turning it into something that you do know.”
Only then can surgeons begin to participate meaningfully in the decisions shaping their future.
Where the system is headed
Dr. Schwartz sees the trajectory as increasingly clear: value-based care is moving from optional to inevitable.
“With CMS, it’s going toward some form of value-based care,” he said. “By 2030, it’s no longer going to be selected. It’s going to be mandatory.”
Commercial payers, he believes, will follow, and smaller practices may find survival increasingly difficult without scale or leverage. “Either you have to be big enough to have negotiating leverage,” he said, “or the smaller you are, the harder it is going to be to survive in the commercial environment.”
Employers, meanwhile, are expected to push more aggressively toward centers of excellence and higher-value care models.
Independence, ASCs and the economics of survival
For many orthopedic surgeons, ASCs have become central not only to strategy, but to autonomy. “If you want to be independent, you have to have some ownership in a surgery center,” Dr. Schwartz said, particularly as professional fees decline.
Ownership, he noted, can help offset reimbursement pressure through facility distributions.
Private equity’s role, however, remains less settled. “It was pretty popular a few years ago when interest rates were low,” he said. “My sense is that that’s changing a little bit.”
Whether the specialty has seen the peak of orthopedic platform consolidation is still uncertain.
“I think the jury’s still out,” he said.
What residents need before they graduate
If Dr. Schwartz could change one thing about orthopedic training, it would not be another clinical module. It would be preparation for leadership.
“I think it’s a combination of leadership and advocacy,” he said.
Physicians, he believes, must seek influence earlier, within hospitals, practices and government. “We need to bring more and more attention to things that are happening,” he said.
Because orthopedics is no longer practiced solely in the operating room. It is practiced inside a system of reimbursement, regulation and policy that physicians can no longer afford to navigate blindly.
Surgeons do not need to become MBAs. But they do need fluency.
As Dr. Schwartz notes, physicians do not just need a seat at the table. They need help finding the table, and learning how to speak the language once they get there.
