Payment Policy is Access Policy

During an annual budget meeting, an orthopedic practice leadership team considers many decisions (everything from recruiting and building to service additions, clinic expansions, and more). Each decision carries financial implications and affects the access patients in a community have for themselves and their families.  

Balancing reimbursement with the resources required to deliver safe, timely, high-quality care is an ongoing challenge. Research has consistently shown that physician payment and practice resources influence the availability, distribution, and delivery of medical services, particularly in rural and underserved communities (Bodenheimer & Pham, 2010; Medicare Payment Advisory Commission [MedPAC], 2023). As the cost of doing business continues to trend in the opposite direction of reimbursements, our advocacy efforts have never been more important, and they become more effective when we help policymakers understand that relationship through specific, credible examples from our practices. 

The proposed calendar year 2027 Medicare Physician Fee Schedule makes this conversation particularly timely. Among the proposals drawing concern from AAOS are changes to joint arthroplasty work relative value units and payment for separately identifiable evaluation and management services provided on the same day as procedures. AAOS has called for CMS to reconsider these changes, citing potential consequences for practice sustainability and patient access (American Association of Orthopaedic Surgeons [AAOS], n.d.). Practice leaders can contribute to that discussion by explaining what a policy will ultimately mean for local patients and communities. 

A projected revenue reduction is one part of the story. The next step is to evaluate how it could affect the practice’s ability to hire clinical staff, add appointment capacity, invest in technology, or maintain services in a particular community. Payment levels directly influence whether practices expand, reduce services, or avoid operating in areas where the cost of delivering care is high relative to reimbursement (MedPAC, 2023). 

Consider a patient who needs an evaluation and a medically appropriate procedure during the same visit. Receiving both services can reduce travel, time away from work, and the need for a family member to provide transportation. These considerations are especially important for patients who live in rural areas, have limited transportation, or must take unpaid time away from work. Research on access to specialty care has shown that distance, transportation, and appointment availability can create meaningful barriers to timely treatment (Syed et al., 2013). Evaluating payment changes affecting these encounters should include consideration of those practical benefits. Financial analysis gives us a starting point. Connecting that analysis to the patient's experience gives policymakers a clearer understanding of what is at stake. 

Orthopedic administrators have access to information that can make advocacy more useful and precise. Scheduling systems, revenue cycle reports, staffing plans, and patient feedback can help explain how policy affects care delivery. A practical approach begins with three questions: