Here’s what you should consider before expanding your ownership structure in 2026.

1. Understand why partnership matters

In a surgeon-owned practice, partnership alters the internal balance of ownership. Partnership carries consequences beyond productivity metrics. It affects how your practice distributes profits and makes governance decisions. Those dimensions require deliberate structure instead of assuming automatic alignment.

Your governing agreement should explicitly define how equity accrues and how decision-making authority functions within the group. Defined terms in these provisions reduce ambiguity and limit internal conflict.

2. Start with the financial health of your practice

Before offering ownership, you need confidence that your practice operates from a position of strength.

Ownership expansion works when profitability is steady and your business is well-managed day to day. If margins are inconsistent, adding another equity holder can dilute returns rather than strengthen them.

Evaluate performance data that demonstrates operational consistency such as:

• EBITDA Margin: This metric shows how much profit your practice generates from core operations and helps determine whether the business is strong enough to support a structural shift like adding an owner.
• Days in Accounts Receivable: Collection efficiency supports liquidity and protects your owner compensation.
• Payer Mix: A balanced mix of commercial, government, and self-pay revenue reduces reimbursement risk and helps keep your revenue predictable over time.

These measures indicate whether the practice can add another owner without compressing return.

3. Quantify the contribution a partner brings

Equity should correspond to a demonstrable increase in enterprise value. The physician’s addition should improve earning power in a sustained way.

Consider:

• Does this surgeon drive sustainable case volume for your practice?
• Does their specialty expand referral channels or strengthen differentiation in your market?
• Will their involvement improve your contracting leverage or operational oversight?

If projected impact does not translate into measurable financial improvement, continued employment may represent the more disciplined option.

4. Structure the buy-in carefully

A buy-in model should align with current valuation and connect ownership to future distributions in a transparent and defensible way.

Use a clearly defined valuation formula and document it in the operating agreement.

5. Address legal and regulatory exposure

Ownership arrangements must comply with federal referral and compensation laws. Improper structuring can create avoidable regulatory risk for your practice.

Governing documents should specify how authority functions and how ownership transitions occur. Well-drafted agreements protect the practice as it grows and ownership evolves.

6. Evaluate the competitive environment

Orthopaedic practices compete in an environment shaped by consolidation and scale. Larger entities continue to influence recruitment and contracting. Although private equity ownership represents a minority share of practices, its presence affects negotiating leverage across markets.

If independence remains central to your strategy, expanding ownership may strengthen your standing in negotiations. With uncertain growth projections, increasing ownership complexity may limit flexibility at a time when adaptability carries real value.

7. Qualitative factors still matter

Financial metrics matter, and shared expectations around leadership, accountability, and long-term direction are equally important. Misalignment weakens the durability of the partnership within your group.

Final considerations before expanding ownership

Before proceeding with an additional ownership position in 2026, confirm the following conditions are met.

• Financial benchmarks demonstrate sustained improvement.
• The physician’s addition produces measurable economic contribution.
• Valuation methodology is documented and defensible.
• Regulatory exposure underwent careful review.
• There is shared understanding regarding the future direction of the practice.

When performance supports expansion and alignment exists, adding a partner can reinforce stability and negotiating strength. When financial contribution or strategic fit remains uncertain, delaying ownership expansion may better preserve the practice’s financial stability and authority structure.

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In expansion market,

In today’s consolidation-driven market, how important is ownership expansion to maintaining independence?

• Very important
• Somewhat important
• Neutral
• Not important
• We are exploring acquisition or sale instead

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A snapshot of where orthopaedic subspecialty training stands

According to the NRMP’s Results and Data: Specialties Matching Service 2025 Appointment Year report, 14,833 active applicants submitted certified rank order lists for 14,620 fellowship positions. The Match filled 12,390 of those positions, producing an overall match rate of about 83.5 percent, with 6,334 programs participating. At this scale, fellowship training has become one of the primary forces shaping who enters the orthopaedic workforce and how subspecialty services will be staffed in the near future.

This continued expansion reflects a profession that increasingly relies on advanced, focused training to meet clinical demand. Fellowship education now influences how orthopaedic departments define coverage needs and how practices respond to patient expectations for subspecialty care. Even for surgeons well beyond training, the data helps explain why hiring often prioritizes specific skill sets and why generalist roles have become less common in many settings.

What the numbers tell you about competition

An increase in fellowship positions may suggest less competition, but the data points in another direction. An overall match rate of roughly 83.5 percent means a meaningful share of applicants still do not secure positions, and demand remains concentrated in certain subspecialties. This aligns with what many surgeons experience when recruiting or referring, where access to specific subspecialty expertise remains limited despite overall workforce growth.

Orthopaedic-specific fellowship reports reinforce this uneven demand. Applicant interest continues to cluster in some subspecialty areas, while others fluctuate from year to year. These patterns help explain why coverage gaps persist in some practices and regions, even as training positions increase nationally. They also reflect how fellowship choices respond to perceived market demand and evolving models of orthopaedic care delivery.

The value of Fellowship Match data lies in how it clarifies trends already visible across the profession. It shows how subspecialty supply may shift, why recruitment challenges endure, and where pressure points are likely to emerge. When viewed through this lens, the data helps explain the structural changes shaping orthopaedic practice today rather than simply reporting who matched where.

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Private equity interest in orthopaedics has become a constant backdrop rather than a surprise. Once discussions move past valuation and structure, a more difficult question often emerges. How the partnership will affect your professional life over time can matter more than the terms that look most attractive at signing.

Understanding that impact requires looking beyond the initial transaction and considering how control, flexibility, and leverage may change after ownership changes.

Long-term autonomy risks are often underestimated

Loss of autonomy tends to emerge gradually rather than all at once. The initial transaction is rarely the final change in ownership, and each transition can further move leverage away from physicians.

If your practice changes hands again, you may have limited influence over the direction that follows. Agreements that felt workable early on can become more restrictive as circumstances change, particularly when new stakeholders bring different strategic goals.

Regulatory scrutiny at the state level reflects growing concern about how investor control can affect clinical independence and professional mobility. New oversight efforts aimed at healthcare private equity deals highlight the risks physicians may face once leverage transitions away from practice owners.

Limitations on mobility and reduced negotiating leverage often become clearer later in the relationship. By the time those constraints are fully visible, your options may be narrower than you anticipated at the outset.

What you should assess before moving forward

This is the point where information becomes preparation. Before entering a deal, it can help to move from listening to the pitch to evaluating how the partnership would function after the transaction closes.

The most meaningful signals tend to come from how authority is defined, how expectations are enforced, and how much flexibility remains once ownership changes hands. Paying close attention to how governance is described versus how it is contractually structured can reveal how decisions will actually be made.

The same applies to performance expectations. How they are monitored and adjusted over time will shape your daily professional experience more than initial projections suggest. It also becomes important to consider how the partnership would feel if circumstances change, whether through leadership turnover, strategic changes, or a future sale.

Evaluating the deal through that longer lens can clarify whether the partnership supports your professional goals or limits them over time. Legal and industry analyses emphasize the importance of understanding these dynamics in an environment where both deal activity and regulatory pressure continue to increase.

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Before on? want

Before signing a private equity agreement, what would you most want greater clarity on?

• How authority shifts after ownership changes
• How performance expectations are enforced
• How future ownership changes affect physicians
• How easily physicians can exit the partnership

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What often gets missed in those early discussions is how dramatically a deal can reshape how your practice is governed and operated over time, especially in ways that only become clear after key decisions are already constrained.

The most significant challenges rarely appear in the headline valuation. They tend to emerge later, once you are functioning under a different set of priorities. Policymakers and physician organizations have increasingly raised concerns about how investor influence can affect professional autonomy and clinical decision-making.

Governance changes happen faster than expected

Governance is often the first area where meaningful change shows up after a transaction closes. Private equity deals frequently emphasize physician input and operational flexibility, but governance structures tend to fluctuate quickly in practice.

You may notice that decision-making authority changes in ways that are not immediately visible, particularly when approval requirements and reporting structures are described broadly rather than defined precisely. Decisions that once stayed within the practice can begin to require external sign-off, altering how quickly and independently you are able to act.

Even if you retain an ownership stake, your influence over how the practice operates can narrow over time. Strategic direction often becomes shared or redirected, which makes it important for you to understand how authority will function once the transaction is complete rather than relying on early assurances. Reporting on consolidation in orthopaedics has highlighted how these changes can limit physician control even when clinical independence is emphasized in principle.

Ethical analyses have also noted that the financial priorities driving private equity ownership can create tension with traditional clinical values. That tension often becomes more visible as business objectives begin to form operational decisions.

Productivity benchmarks are not suggestions

Productivity expectations tend to feel very different after an acquisition. After closing, targets are often framed as performance goals, but you are likely to experience them as enforceable expectations.

Your activity levels and output may be tracked more closely once new reporting systems are in place. Deviations rarely go unnoticed. Over time, these benchmarks can affect scheduling, case mix, and workload in ways that extend beyond compensation alone.

If your current practice patterns already align with these expectations, the transition may feel manageable. If they do not, you may feel pressure that affects how you work day to day and how your performance is evaluated over time. Commentary on physician engagement with private equity has underscored how these expectations can influence professional satisfaction and perceived autonomy.

Exit pressure influences daily operations

Exit planning influences operations earlier than many physicians expect. Private equity firms operate on defined investment timelines, and your transaction is almost certainly structured with an eventual transition in mind.

That reality determines how decisions are made inside your practice, even when it is not openly discussed. Industry analyses from 2025 and early 2026 describe investor strategies that emphasize positioning for future exits alongside operational performance.

You may begin to notice that operational choices increasingly reflect preparation for a future sale rather than long-term internal priorities. Over time, this can turn focus toward financial presentation and short-term performance indicators, even when those priorities differ from how your practice previously defined success.

In Part 2, Orthopaedics 411 will focus on how you can evaluate these issues before you commit to a deal.

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Which post-closing change would concern you most in a private equity partnership?

• Reduced control over clinical or operational decisions
• Increased productivity tracking and performance expectations
• Pressure tied to future exit timelines
• I have not considered how post-closing changes could affect my practice

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Encourage gentle, consistent movement

Many patients rest more during the holidays, thinking it will ease pain. In reality, long periods of inactivity can worsen stiffness. You can help by encouraging simple, consistent movement. A short walk after a meal or stretching before bed keeps joints flexible and circulation strong. Recommend light activities that fit naturally into the holiday routine, such as walking with family or helping with easy tasks around the home.

Help patients prepare for travel

Holiday travel is one of the most common triggers of joint discomfort. You can help patients plan ahead by discussing supportive travel habits. For those driving, suggest breaks to walk and stretch every couple of hours. For those flying, remind them to book aisle seats, wear compression socks, and bring a small cushion for back support. Lightweight rolling luggage and firm-soled shoes can make a noticeable difference in reducing strain.

Advise on cold-weather comfort and safety

Cold temperatures often worsen joint stiffness. Encourage patients to dress in warm layers and wear shoes that provide both cushioning and traction. In crowded gatherings or busy kitchens, falls can happen easily. Recommend slowing down, holding onto railings, and avoiding heavy lifting or carrying items that could throw off balance. These small precautions help keep patients comfortable and confident through holiday activities.

Reinforce smart eating and hydration habits

Diet can influence inflammation and joint pain. Encourage patients to enjoy their holiday favorites but stay mindful of excess salt and sugar. Hydration also matters, since joint tissue needs water to stay resilient. Foods that support joint health — such as leafy greens and roasted vegetables — can easily fit into festive meals. A quick discussion about balanced nutrition helps patients stay focused on long-term wellness while still enjoying the holiday table.

Promote pacing and pain management

Holiday gatherings can be demanding for those managing chronic pain. Encourage patients to pace themselves and listen to their bodies. Rest periods and prescribed medications can help prevent overexertion. Supportive braces or canes can help as well. Reinforcing that these tools promote independence rather than limitation helps patients feel more confident in using them.

A season to celebrate movement

Thanksgiving offers an opportunity to remind patients how valuable mobility truly is. Even small steps toward staying active are worth celebrating. By helping them plan ahead and manage their activity level, you give them the chance to move with gratitude through the season and enjoy the freedom that comes with it.

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Although small adjustments to certain hip and knee replacement codes softened the immediate impact, they did little to change the long-term picture. Without a mechanism that accounts for inflation, your margins continue to shrink while operating costs climb.

As a result, this financial pressure has united orthopaedic organizations around a single goal: A stable, sustainable payment system that values the complexity of the work you perform. The growing financial strain on orthopaedic surgeons like you has sparked a nationwide advocacy movement aimed at securing fair, lasting reimbursement reform that protects both patient access and the future of orthopaedic care.

Advocacy efforts are gaining traction

In response to these pressures, AAOS and its partner societies have taken a more coordinated approach to advocacy. Their targeted outreach now focuses on showing how repeated payment cuts restrict access to care and limit practice viability.

The AAOS Advocacy Action Center gives you a direct channel to lawmakers and keeps you current on policy activity that affects your practice.

AAHKS continues to publish clear breakdowns of how rate proposals affect arthroplasty practices nationwide. In parallel, AAOS Now highlights practical tools such as Code-X, which help you maintain accurate reporting and reduce billing denials. 

Taken together, these actions show a profession actively working to influence policy rather than waiting for change to arrive on its own.

What’s next for 2026

Looking ahead, you can expect more updates that will directly affect your practice. The North American Spine Society (NASS) has flagged several changes in the proposed 2026 fee schedule that could reshape how orthopaedic surgeons organize their work. 

Some of the planned updates would add more procedures to outpatient lists and gradually phase out inpatient-only designations. These adjustments may influence where you perform complex cases, particularly in spine and joint care.

A new payment model called WISeR will also begin testing in select states. It will use automated reviews before reimbursement is issued. The stated goal is efficiency, though many practices expect more oversight and slower payment cycles.

Collectively, these developments point toward a payment environment that will demand more preparation, documentation, and awareness from you and your team.

Keeping your practice resilient

While national advocacy remains vital, daily operations are where you feel the impact most directly. Using updated coding tools helps align your documentation with payer standards. This reduces disputes and improves the likelihood of successful appeals.

In addition, maintaining regular communication with advocacy teams helps your perspective reach policymakers. Lawmakers respond more effectively when they hear firsthand how payment trends influence patient care, staffing, scheduling, and workflow management in real clinical environments.

If your practice depends heavily on Medicare, staying alert to regional payment differences can prevent financial surprises. Local adjustments often diverge from national averages, creating challenges that require strategic planning.

As outpatient surgery continues to expand, reviewing your internal policies helps you stay aligned with new regulations. It’s also worth monitoring how telehealth coverage, prior authorization, and documentation standards evolve under updated federal guidance.

The bigger picture

Ultimately, declining reimbursement rates point to a deeper imbalance in how physician services are valued. You provide technically demanding care that requires significant training and resources, yet payments often fail to reflect that expertise.

For this reason, AAOS, AAHKS, and NASS are aligning advocacy efforts with current data to drive meaningful reform. By staying active in both clinical and policy work, you can help preserve patient access and protect the future of orthopaedic care.

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What's the biggest financial pressure point in your practice right now and how are you addressing it?

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Noncompete clauses have long shaped physician employment contracts by restricting opportunities once a position ends. For orthopaedic surgeons, these agreements can interfere with patient continuity and create career disruptions through relocation requirements or costly buyouts. The FTC’s nationwide noncompete ban never took effect, and the agency recently voted to vacate the rule, leaving enforcement to state law and case-by-case actions. With states tightening terms and courts weighing in, the precise contract language you sign now carries greater weight for future practice options.

Map your recruiting targets before you sign.

Today’s constraints are state-specific and uneven. A current policy tracker notes that noncompetes are governed at the state level, that four states ban them entirely, and that many more restrict their use in defined ways. If you plan to change employers across state lines, review statutory limits up front rather than after receiving a draft.

Healthcare carve-outs are getting tighter.

A recent legal update focused on health care reports a clear trend toward narrower, more prescriptive physician clauses. Many states now confine duration to about one year and define geographic scope by fixed miles or political boundaries, with examples that include Louisiana’s parish-based limits, Maryland’s ten-mile cap, Connecticut’s fifteen-mile cap, West Virginia’s thirty-mile cap, and Tennessee’s allowance of up to two years. These laws also increasingly tie enforceability to how the relationship ends, such as voiding a restriction after termination without cause or when no bona fide renewal is offered.

Texas is a preview of the details that matter.

Texas enacted SB 1318 with effective date September 1, 2025, tightening physician noncompetes to one year in duration and a five-mile radius from the primary practice location. Buyouts cannot exceed the physician’s total annual salary and wages at termination, and a noncompete is void if you are terminated without good cause. The statute also extends similar restrictions to dentists, nurses, and PAs. If your agreement involves multiple clinics, clearly defining the “primary” site reduces later disputes.

What this means when you negotiate.

Expect counsel to anchor duration near one year and to hard-code narrower distance terms, especially in hospital-employed roles. That pattern is reflected across several state statutes cataloged in recent health care legal analysis. When recruiting, confirm whether a candidate’s current state treats health-care-specific clauses differently than general worker clauses, then align signing timelines to any new-law effective dates shown on state trackers.

A quick scenario to sanity-check your clause.

Hypothetical: You leave a hospital-employed shoulder and elbow position in Austin and the agreement restricts you for one year within five miles of your primary clinic, with a buyout pegged to your last year’s salary. Under SB 1318 those terms reflect the new Texas framework, and the restriction would be void if the hospital ended your contract without good cause.

Bottom line.

With the FTC ban off the table, your mobility and your group’s recruiting strategy depend on state law and specialty-specific rules. Use current legal summaries to set realistic guardrails before the offer stage, and document the “primary practice location” with precision in any agreement.

Disclaimer: This article is intended for informational purposes only and should not be taken as legal advice. Physicians considering employment contracts should consult qualified legal counsel familiar with state and federal law.

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What’s one clinical or business lesson you wish you’d learned earlier in your orthopaedic career?

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1. Site-of-Service Rules Are Steering More Procedures to Outpatient Settings

CMS continues to remove procedures from the inpatient-only list, encouraging more surgeries, such as total shoulder arthroplasty and lumbar spine cases, to be performed in ambulatory surgical centers (ASCs).

• What This Means for You: If you’re affiliated with a hospital, you may see more procedures redirected to outpatient environments. If you’re invested in an ASC, this could bring opportunities to expand case volume.
• What You Can Do: Review your case types and facility access. Consider building or expanding ASC partnerships if outpatient capacity is limited.

2. Prior Authorization in Medicare Advantage: Streamlining, Not Expanding

The Centers for Medicare & Medicaid Services (CMS) is introducing rules aimed at streamlining and improving the prior authorization process, though requirements will still vary by plan. CMS changes focus on faster approvals, fewer requirements for some services, insurer commitments to standardize processes, and new oversight committees to ensure fairness and transparency.

• What This Means for You: Overall, MA prior authorization in 2025 is becoming more efficient and transparent, not stricter. Still, clinics must monitor plan-specific rules, as insurers are adjusting codes both up and down.
• What You Can Do: Stay proactive by tracking each payer’s updates and using staff or software tools to manage changing requirements and approval timelines.

3. Reimbursement Reductions Are Affecting In-House PT and Imaging

The 2025 Medicare Physician Fee Schedule includes payment reductions for physical therapy and diagnostic imaging, particularly when offered in-office.

• What This Means for You: If your practice includes integrated PT or imaging, these changes could impact financial performance and patient access.
• What You Can Do: Consider ways to strengthen care coordination, improve throughput, or participate in alternative payment models that reward efficiency.

4. Stark Law Updates: Inflation Adjustments in 2025

For 2025, the Centers for Medicare & Medicaid Services (CMS) did not introduce new categories of Stark Law exceptions. Instead, the updates focused on applying annual inflation adjustments to the monetary limits of existing exceptions.

• What This Means for You: While the scope of exceptions has not expanded, practices should be aware of the updated financial thresholds to ensure compliance.
• What You Can Do: Review the revised limits with your compliance or legal team to confirm your current arrangements remain within allowable thresholds.

5. FDA Enforcement on Orthobiologics Is Getting Stricter

Increased use of regenerative therapies has prompted the FDA to intensify enforcement of biologics that lack approval or appropriate oversight. Treatments involving PRP and stem cells are under particular scrutiny in 2025.

• What This Means for You: If your practice uses biologics outside FDA-defined parameters, you may be at risk for compliance violations.
• What You Can Do: Conduct a full review of your regenerative medicine offerings. Ensure your treatments are either FDA-approved or covered by an IRB protocol.

Resources To Stay Updated

At Orthopaedics 411, we’re committed to keeping you informed on the latest changes shaping orthopaedic practice and healthcare policy. In addition to our coverage, here are a few trusted resources you can use to track regulatory updates:

• American Academy of Orthopaedic Surgeons (AAOS) Advocacy Center
• Centers for Medicare & Medicaid Services (CMS) Newsroom
• FDA Newsroom & Regulatory Updates
• Federal Register – Health and Human Services
• Medicare Payment Advisory Commission (MedPAC)

Final Thought

As an orthopaedic surgeon or practice leader, you need clear visibility into policy changes that affect your clinical and business decisions. Whether you operate independently or within a health system, understanding the rules and responding proactively can help you maintain control over your outcomes and keep your team focused on what matters most, delivering high-quality musculoskeletal care.

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have on think

Which policy change do you think will have the biggest long-term impact on orthopaedic practices?

• Outpatient site-of-service shifts
• Medicare Advantage prior authorization updates
• Reimbursement changes for PT and imaging
• Stark Law threshold adjustments

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1. Recognize when your feedback loops are broken

If someone leaves and you didn’t see it coming, then either they didn’t feel safe sharing concerns or the concerns they shared weren’t addressed. Either way, your loop has broken down.

Sometimes, the only time you hear about issues is during an exit interview. By then, it’s too late. If your team isn’t regularly speaking up, it may be a sign that they don’t feel comfortable doing so. And if you’ve responded inconsistently in the past, addressing some concerns while ignoring others, trust can quietly erode over time.

2. Use structured tools to catch issues early

You don’t have to guess what’s bothering your team. Build a system that collects feedback regularly. That starts with structured tools. Avoid relying on side conversations.

A. Survey data

Surveys help you gather anonymous signals about team sentiment. They work best when you keep the questions focused and act on what you learn.

Pulse surveys can check on satisfaction, workload balance, perceived fairness, or access to resources. Anonymous forms give your team a way to speak up safely. Over time, survey results can reveal early warning signs.

B. Interviews and discussions

Some problems surface only in conversation. You’ll often uncover more during face-to-face or small-group discussions than on a form.

You can hold short check-ins with techs, billers, coders, and schedulers. Even 15 minutes can surface small frustrations. When concerns span roles, a facilitated conversation can help you spot shared obstacles. If people hesitate to speak freely, consider using a neutral third party.

3. Translate feedback into real action

Feedback without follow-through undermines trust. Your team will notice whether anything changes.

Choose a concern that comes up often and fix it fast. Assign someone to own the solution and report progress. Document what’s being changed, who owns the next step, how it will be tracked, and when the next update will happen.

4. Show your team that you’re listening

When you make a change, say so. Small improvements are worth highlighting — especially when they’re tied to something your staff raised.

Let your team know: here’s what we heard, here’s what we’re doing, when it will go into effect, and how we’ll measure it.

Make it specific. For example, if you adjusted how rooms are assigned or updated a shared document, say so clearly.

Use multiple channels to communicate changes. Email summaries, team huddles, printed notices, Slack messages, or in-person reminders all help ensure the message gets across.

5. Keep refining your approach

No tool lasts forever. Once your system is in place, keep it fresh.

Revisit your survey questions every few months. If participation drops, try a new format or change the timing. Remove tools that don’t get used and try simpler options.

Step-by-step checklist

This checklist can help build a consistent, lightweight system for closing feedback loops. You can start with a few actions, then expand from there.

1. Send regular pulse surveys to monitor morale and workload.
2. Keep an anonymous suggestion channel open year-round.
3. Make time for short 1:1s and structured check-ins.
4. Act on recurring problems that affect multiple roles.
5. Report back on what was said, what’s being fixed, and who’s responsible.
6. Refresh your process quarterly to keep it relevant.

Why your response matters

If your team sees that feedback leads to real outcomes, they’re more likely to stay. They’re also more likely to participate in the process again.

One study found that practices with working feedback systems had up to 27% lower turnover. These systems also helped improve engagement and trust in leadership.

Sample tools

These examples are starting points. Tailor them based on how your team works and communicates.

Sample pulse survey questions

• “On a scale of 1 to 5, how manageable is your current workload?”
• “Do you feel like your contributions are acknowledged?”
• “Have you had trouble with scheduling, supply access, communication breakdowns, or lack of leadership availability in the last 30 days?”

Sample follow-up message

“You told us weekend coverage wasn’t fair. We’re piloting a rotating shift system next month. After the first cycle, we’ll ask for feedback again.”

Final thoughts

When someone leaves unexpectedly, it’s often not about a single issue. It’s usually the result of small breakdowns that go unaddressed for too long. A functioning feedback system gives you the chance to catch those breakdowns before they spread. If your staff sees that you’re willing to listen and act with purpose, they’re more likely to stay. When your response feels measured and visible, you begin to earn long-term trust. That kind of trust doesn’t come from policies or slogans. It comes from what you choose to do when concerns are brought to you.

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Which of the following changes do you believe would most improve your team’s communication or morale?

• More frequent team check-ins or huddles
• Improved transparency from leadership
• Clearer roles and responsibilities
• Recognition and appreciation for hard work
• Better tools or technology for communication
• Reduced workload or more balanced schedules
• Opportunities for team bonding or social connection

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Why bundled payments are getting another look

The old CMS models focusing on inpatient joint replacements laid a foundation, but newer pilots go further. Many now target outpatient settings and coordinate care across longer timeframes. At Vanderbilt, for example, the MyHealth Bundles team built a program for employers that includes procedures like maternity and spine surgery, along with joint replacement. Their approach centers on centralized patient intake and care navigation infrastructure. While specific outcomes haven’t been published, bundled programs like this are often intended to reduce unnecessary imaging, cut down on repeat visits, avoid complications, and improve patient retention.

Groups with high surgical volume may be drawn to models that reward standardization. Some large academic systems are exploring bundled reimbursement tied to quality targets, which could give surgeons more influence over care pathways while still holding them accountable for outcomes. For practices operating across multiple ASCs, standardization of perioperative care is often seen as a potential way to improve both efficiency and consistency, although formal results have not been widely shared.

The pain points are real, and mostly financial

Even among practices open to value-based payment, bundled models can introduce friction. Reimbursement delays often follow incomplete documentation or payer-specific coding requirements. Denials in orthopaedics are frequently attributed to issues like mismatched modifiers or software limitations, especially when legacy systems are involved.

Some ASCs have responded by reworking staff workflows or updating their EHR templates to reduce billing errors. These tactics are commonly discussed as operational improvements, though detailed outcomes specific to orthopaedic bundles remain limited in published literature. Even when infrastructure is updated, most software still lacks the ability to fully track cost allocation across entire surgical episodes.

Financial risk is another barrier. Some bundles introduce downside exposure before practices have the volume to absorb it. Others include reconciliation timelines or contract terms that create unpredictability in cash flow.

A few are making it work. Some are profiting

Some orthopaedic groups are testing bundled models and building operational systems to support them. For instance, the Centers for Advanced Orthopaedics has previously explored episode-based models in spine and joint care, supported by a dedicated care management team. While outcomes have not been formally published, public statements from the group suggest bundled contracting has been a useful strategy for engaging payers and employers.

Hattiesburg Clinic offers a broader case study in value-based care integration. The clinic has layered analytics into its risk-based infrastructure and added physician-level performance feedback tools. While the clinic’s bundle-specific results are not detailed, its long-standing experience with coordinated care makes it a frequent point of reference for those looking to integrate financial and clinical data.

What makes a bundled model successful

Groups seeing early traction with bundled models tend to do a few things differently:

1. They target narrow procedure categories like elective joint replacement or minimally invasive spine to reduce variability.
2. They engage patients early, often starting before the pre-op appointment and continuing well into recovery.
3. They use dashboards to monitor cost trends, flag high-risk patients, and track adherence to protocols.
4. They set firm entry points such as volume thresholds, staffing requirements, or payer commitments. These criteria must be met before greenlighting new bundles.

Internal coordination also matters. Surgeons, schedulers, billing teams, navigators, and sometimes IT leads all work from the same playbook. This minimizes communication gaps that lead to missed documentation or patient confusion.

Where bundled payments may be headed

The future of bundling depends on consistent design, reliable contract terms, clear reporting standards, and supportive infrastructure. Some payers are exploring hybrid reimbursement, while others are recommitting to episode-based models. For orthopaedic surgeons, bundled contracts may offer a way to exert more control over margins and compete more directly on measurable value.

That potential depends on internal readiness. Without access to real-time data and aligned workflows, the burden of coordination may outweigh any gains. But for groups with infrastructure already in place or partners willing to invest in it, bundled payments continue to be one of the few models where outcomes and revenue can move in the same direction.

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payments viable path

Do you believe bundled payments offer a viable path to improve both care and revenue?

• Yes, with the right systems in place
• Possibly, but it’s not proven yet
• Not really—it creates more risk than reward
• Unsure

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