Across the country, health systems are racing to open ASCs, recruit orthopedic surgeons and stake out regional territory before competitors do. Bryan Kelly, MD, thinks most of them are solving the wrong problem.
“It’s easy to fall into the idea that orthopedics is just about surgery,” said Dr. Kelly, president and CEO of New York City-based Hospital for Special Surgery, the institution that has topped U.S. News & World Report’s orthopedic rankings for more than 16 consecutive years.
In Dr. Kelly’s view, the organizations that win the next decade of musculoskeletal care will not be the ones with the most operating rooms. They will be the ones who treat orthopedics as something closer to a lifelong relationship with a patient’s body, running from prevention and performance through rehabilitation, regenerative medicine and, eventually, surgery if necessary.
“HSS is not just a place you go when you’re injured,” he said. “It’s a platform that serves the needs of the entire musculoskeletal care continuum.”
A demand curve bending upward
Dr. Kelly believes orthopedic surgery is entering a sustained surge in demand, driven by demographics that are largely fixed. Musculoskeletal conditions already rank among the largest categories of U.S. healthcare spending, accounting for hundreds of billions of dollars annually in direct patient care costs, he said
As members of the baby boomer generation age deeper into their 70s, the volume of hip fractures, advanced osteoarthritis and degenerative spine conditions is expected to climb sharply.
“There’s actually an increasing demand for orthopedic surgery,” he said.
But the demographic story is only half of it. Patients in their 60s and 70s are no longer content to manage pain and slow down. They expect to keep running, skiing, lifting and traveling — and they are arriving in orthopedic offices asking how to stay that way.
That expectation, Dr. Kelly argues, is what makes a surgery-only strategy increasingly outdated.
“If you’re not thinking about it from a holistic perspective, then you’re probably not serving the whole musculoskeletal health continuum as effectively as possible,” he said.
That thinking has shaped HSS’s investment in performance physical therapy, regenerative medicine research, metabolic bone health and a lifestyle medicine program, services that historically lived outside the walls of an orthopedic hospital.
What today’s surgeons are actually looking for
Even as competition for orthopedic talent intensifies nationally, Dr. Kelly believes compensation and brand prestige have become table stakes rather than differentiators. The applicants entering the field today, he said, are extraordinary.
“These are incredibly talented people,” he said. “I wouldn’t have been able to compete against them when I was applying.”
What those surgeons are weighing, in his telling, is the texture of the environment they would spend a career inside. At HSS, every clinical, research and capital decision is made through a single lens, orthopedics, which means surgeons are not competing internally with cardiology, oncology or transplant programs for resources or attention.
“It’s all orthopedics. It’s all musculoskeletal health,” he said.
The institution runs an orthopedic residency that takes nine new physicians per year over a five-year program, plus roughly 80 fellows annually across 11 subspecialties.
Within sports medicine alone, some surgeons spend their careers focused almost entirely on the shoulder; others on cartilage restoration, ligament reconstruction or hip preservation. That depth, Dr. Kelly said, is part of the draw, alongside what he describes as the connective tissue of any serious academic program.
“Research serves as the backbone of innovation,” he said.
The expansion trap
As health systems race to build out orthopedic networks, Dr. Kelly believes most underestimate a single risk: that growth itself can quietly destroy the thing being grown.
“It’s very, very hard to maintain a consistent culture and consistent quality metrics if you’re acquiring rather than building,” he said.
Acquisitions move faster than organic expansion. They also, in his experience, dilute the workflows, expectations and shared identity that define a high-performing orthopedic program.
HSS’ own model has leaned in the other direction, what Dr. Kelly calls strategic, organic regional growth, anchored by ambulatory hubs that combine surgery, advanced imaging, rehabilitation and physician offices under one roof, with smaller satellite sites serving as entry points into the system.
The model also reflects a structural reality of modern orthopedics: surgery has already left the hospital. Roughly 80% of orthopedic procedures are now performed in ambulatory settings — a shift driven by reimbursement, technology and patient preference all pulling in the same direction, according to Dr. Kelly.
“Trying to bring orthopedics to people, rather than making them come to us, is a better experience for patients,” he said.
HSS now operates 26 regional sites across the tri-state area and Florida. Maintaining the feel of the main Manhattan campus across that footprint, Dr. Kelly conceded, is the harder problem.
“The biggest challenge with growth is that it can either dilute quality or erode culture,” he said.
The next frontier is data
If reputation and surgical volume have historically separated elite orthopedic programs from the pack, Dr. Kelly believes the next differentiator is something less visible: the ability to centralize and operationalize enormous volumes of musculoskeletal data, clinical, imaging, operational, financial and patient-reported.
“The ability to start building platforms that can actually influence the way people are thinking or augment clinical care pathways is becoming really powerful,” he said.
The implication runs in two directions. For patients, better data means better-calibrated treatment pathways and clearer outcome predictions. For training programs, it means residents and fellows learn inside an environment where decisions are continuously informed by what has worked and what has not. As orthopedics moves further toward value-based contracts and patient-reported outcome measures, that infrastructure is becoming a competitive moat.
“Those who have the best data and are using the data in the best way, that’s going to become really, really powerful,” he said.
What actually builds a leading program
When asked what a health system trying to build a top orthopedic program needs to get right from day one, Dr. Kelly did not hesitate.
“They need the right people,” he said. “And I didn’t say they need the right surgeons. I said they need the right people.”
Orthopedic care, in his framing, is closer to an operating system than a service line. The surgeon is one node. The nursing staff, physical therapists, imaging technicians, administrative team and post-operative care pathways are all part of what determines whether a patient ends up doing well, and whether the program ends up being one people want to work in, train at or refer to.
After three decades inside the institution that wrote much of the modern playbook for orthopedic care, that is the lesson Dr. Kelly keeps returning to. Strategy, scale and technology matter. But none of them, he argues, survives contact with the wrong culture.
“It’s all the people,” he said. “It’s not just the surgeons.”
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