The reimbursement structure and Medicare fee schedule in orthopedics and healthcare has slipped in recent years, leading to concerns from orthopedic surgeons and practices.
CMS issued its final policy changes for the 2026 Physician Fee Schedule in October, which includes a less than 4% increase from 2025.
Labor and supply costs have only continued to increase, leading to smaller margins for orthopedic groups to work with amid reimbursements and programs that simply aren’t keeping up.
Allison Farmer, CEO of Durham, N.C.-based EmergeOrtho, has concerns about the long-term implications regarding access to care.
“At a federal and a state level healthcare reimbursement infrastructure is just so unstable,” Ms. Farmer told Becker’s. “We’re seeing all the indicators of a real future problem. I’m concerned from a Medicare standpoint, that Medicare and Medicare Advantage participants are going to see a drastic decline in the doctors that will serve them.”
The North Carolina Medicaid program is tracking to turn into a dire funding situation. That doomsday scenario where the program runs dry is something that EmergeOrtho has to plan for.
“We have cash pay options for people that need to complement their insurance,” Ms. Farmer said. “We are urging people to call their insurance company and call their benefits manager at their employer if they’re not getting the benefits that they’re paying for. It’s a tough situation because the emergency rooms are going to become the health departments.”
It’s not all doom and gloom, though. There is a system that can work, but that system has to be built sustainably.
“We have to stop wasting the billions of healthcare dollars and cut out the fraud we have now,” Ms. Farmer said. “I do think that there is a sustainable model for Medicare, Medicare Advantage and Medicaid. I think it can be sustainable for providers and hospitals because it was sustainable decades ago.”
