As chair of orthopedics at Cedars-Sinai in Los Angeles, Mark Vrahas, MD, has spent his career building programs that balance excellence in education, clinical care and research.
Today, he sees the field of orthopedics standing at a pivotal moment — one defined by workforce strain, financial uncertainty and the challenge of sustaining value in patient care.
The specialty, he said, faces mounting headwinds that make it increasingly difficult to expand training programs or meet rising patient demand.
“We’re at a difficult crossroads because there are so many headwinds for medicine right now,” Dr. Vrahas said. “As important as it would be to increase the number of training spots, nobody’s really able to do that because of funding ambiguities. Nobody knows what’s going to happen over the next year, two years, three years — and it certainly doesn’t look promising.”
That uncertainty directly affects patient access, particularly in rural regions already struggling to recruit and retain orthopedic surgeons. While large metropolitan areas like Los Angeles have a steady supply of physicians, many parts of the country are facing widening care gaps.
“It speaks to access, especially in rural areas — but moreover, across the country,” Dr. Vrahas said.
With limited ability to grow residency programs, Dr. Vrahas’ focus has turned to retention — ensuring that surgeons already at Cedars-Sinai stay engaged and supported. Retaining talent, he said, now depends less on compensation and more on culture.
“With declining reimbursements and the high cost of living in cities like Los Angeles, we focus on creating a supportive, enjoyable environment where people want to stay,” Dr. Vrahas said.
That emphasis on culture and quality extends beyond staffing. Under Dr. Vrahas’ leadership, Cedars-Sinai has made data analysis central to its approach to value-based care. The department participates in all of the orthopedic bundled payment programs, closely tracking performance metrics across the continuum of care.
Cedars-Sinai has participated in bundled payment programs for years, he said, tracking key performance metrics that drive value-based care.
For Dr. Vrahas, however, value extends beyond financial efficiency. Over the past nine years, Cedars-Sinai’s orthopedic department has collected patient-reported outcomes across every service line — measuring physical function, pain and depression.
The data revealed that about 16% of orthopedic patients had significant depression.
“To address that, we brought a social worker into our orthopedic clinics,” Dr. Vrahas said. “Orthopedic surgeons aren’t trained or equipped to manage anxiety and depression, so the social worker helps connect patients with the resources and programs they need.”
That initiative has evolved into a new study that uses virtual therapy to help orthopedic patients manage anxiety and depression.
“We hope that will decrease catastrophization, improve outcomes and decrease opioid use,” he said. “That was all informed by collecting the measures and noting that a lot of our patients had unrecognized depression.”
Even as Cedars-Sinai invests in patient-centered innovations, financial pressures continue to loom.
“We’ve maintained a good margin over the years, but we’ve done it by cutting a fair amount from our budget — mostly in nonpatient-facing areas,” Dr. Vrahas said. “Now we’re sort of cut to the point where we can’t really cut much more.”
The hospital is taking a proactive approach to maintain stability.
“We have a big initiative to examine our operations across the whole health system to try to identify areas where we could increase revenue or decrease waste without cutting people,” he said. “We’re looking at everything — revenue cycle, clinic access, bundling — with some outside eyes to see where there might be opportunities.”
Despite those efforts to protect the bottom line, Dr. Vrahas said Cedars-Sinai’s priorities remain overwhelmingly mission-driven.
“We have nine goals with metrics for the year,” he said. “Eight of the nine have nothing to do with finances — they’re about quality or growth of the academic mission. Only one mentions being fiscally responsible and increasing philanthropy.”
Looking ahead, he is most concerned about two looming policy shifts that could reshape hospital operations nationwide: potential cuts to Medicaid funding and the possible loss of subsidies for the Affordable Care Act.
“Both those things will greatly decrease the number of insured,” he said. “That means we’ll be taking care of a lot more uninsured people. Hospitals will close, and that will funnel all into Cedars.”
Still, Dr. Vrahas remains steady in his approach, focused on adaptability and purpose through economic and policy uncertainty.
“We’re not in trouble right now,” he said. “We’ve maintained a margin in the upper quartile for several years — but we’re looking ahead to the headwinds.”
