Jay Lieberman, MD, has watched total joint arthroplasty transform over the last decade, tighter perioperative protocols, shorter lengths of stay and an industrywide push toward measuring outcomes with increasing precision.
But the chair of the Department of Orthopaedic Surgery at the Los Angeles-based Keck School of Medicine of University of Southern California and director of USC Orthopaedic Surgery at Keck Medicine of USC said the most urgent threat to the specialty may not be clinical at all.
Instead, he sees a widening gap between the demands being placed on surgeons and the economic reality of meeting them, one that could eventually constrain access for Medicare patients.
“I think at some point surgeons will say, ‘I just can’t do these cases,’” Dr. Lieberman said. “And the problem is, the patient’s going to suffer because then there’s going to be an access issue.”
In his view, the industry’s value narrative has become familiar. The harder question is whether the system is actually built to sustain it.
Outcomes aren’t the new frontier — collecting them is
As payers raise expectations around outcomes measurement, complication avoidance and revision prevention, Dr. Lieberman believes arthroplasty surgeons fully support the concept of value-based care.
What’s changing, he argued, isn’t surgeons’ interest in outcomes. It’s the growing infrastructure required to document them, especially as Medicare increasingly emphasizes patient-reported outcomes and standardized data collection.
For orthopedic programs and private practices, he said, that creates a structural problem: the work is necessary, but the cost has nowhere to go.
The hidden cost of “efficiency”
Total joints are often described as an area where improvements in clinical pathways have reduced costs. Shorter hospital stays and more outpatient recovery are widely framed as efficiency wins.
Dr. Lieberman sees a different reality inside the day-to-day work. When patients go home faster, the responsibility to monitor them doesn’t disappear, it shifts into new systems, new workflows and new staffing needs.
“It actually requires more resources, not fewer,” he said.
Surgeons and health systems, he said, have had to build more support around patients living their recovery outside the hospital, where complications and questions surface differently and require faster response.
“You have to check in on these patients,” Dr. Lieberman said. “They’re not in the hospital for you to see what’s going on.”
At USC, he said that has meant investing in teams designed specifically to manage the post-discharge phase, the phone calls, follow-ups and coordination that keep patients stable, safe and out of the emergency department.
“We have mid-level providers now whose function is to make sure that patients are doing well the night of surgery and the subsequent days. We are in constant contact with these patients for the first two weeks after surgery,” he said.
That work, he emphasized, improves care. But it also raises the question of who is paying for the added labor behind better outcomes.
A gap that shows up as access, not complications
Dr. Lieberman does not expect financial pressure to push surgeons toward lower-quality care. He believes most arthroplasty teams will keep doing what they’ve been doing for years: tightening protocols, tracking performance and trying to prevent readmissions.
Where he sees the real risk is not in rising complication rates, but in participation. As reimbursement declines and the operational burden grows, he worries more surgeons and systems will decide the economics no longer work.
“I think the gap is going to lead to access problems,” Dr. Lieberman said, “and that’s eventually that people will just say, ‘You know, I can’t do this.’”
For him, the breaking point isn’t just frustration, it’s arithmetic. Practices can only absorb so much loss, regardless of how efficient they become.
“It doesn’t matter how much you do in a day if you’re losing money on every one,” he said. “There’s only so much you can make up with volume.”
What tightening access might look like first
Dr. Lieberman said the system has not yet reached a widespread access crisis, in part because many hospitals still accept Medicare and many surgeons remain committed to treating older patients who rely on the program.
But he believes access could tighten gradually and quietly, with limits showing up in scheduling patterns long before they appear as formal policy.
In some markets, he said, practices may begin restricting how many Medicare patients they see, not by publicly rejecting the payer, but by capping intake or narrowing available appointment slots.
If those limits become more common, he warned, the impact would be felt by patients first: fewer options, longer waits and delayed relief for people whose mobility and quality of life are already declining.
Why specialized centers don’t solve the human cost
One solution often raised in arthroplasty is consolidating the most complex cases into
high-volume revision centers. Dr. Lieberman said the concept has clinical logic, but asked what happens to the patient who lives far from an academic hub.
“What would happen if you live 300, 400 miles from the center?” he said. Centralization, he argued, doesn’t eliminate cost. It redistributes it, often onto families.
Long-distance travel for a complex joint case carries its own burdens: transportation, missed work, hotel expenses and the logistics of supporting a patient through a longer recovery.
“Who’s paying for that hotel, and for the gas and for everything else like that?” Dr. Lieberman said.
Those realities, he said, matter because they determine whether a “solution” actually improves care for the entire population or only for the patients who can afford the side costs of accessing it.
The question behind every policy shift
Dr. Lieberman returned repeatedly to the idea that arthroplasty surgeons have done what they were asked to do: improve outcomes, reduce complications, shorten stays and adopt a more data-driven approach.
The unresolved issue is whether the economic framework around Medicare surgery is keeping pace with the expectations being placed on surgeons.
To him, the next chapter of joint replacement isn’t about whether surgeons will keep pushing quality forward. It’s about whether the system will allow them to keep doing it, and for whom.
“We spent our professional lives taking care of them,” Dr. Lieberman said. “But they’re the ones who are going to suffer in the end because they can’t get in.”
