When Healthcare Policy Feels Bigger Than Your Practice
For most of my career as a small independent orthopedic practice administrator, I believed that if we worked hard, provided excellent patient care, treated our staff well, and stayed financially responsible, we would continue to succeed. Lately, though, I find myself lying awake at night wondering whether that is still enough.
What keeps me up is not patient care. It is not our surgeons’ outcomes, our staff’s dedication, or our reputation in the community we have served for more than five decades. What keeps me up are the growing layers of Medicare regulations, quality reporting requirements, reimbursement cuts, and payment models that increasingly feel impossible for small independent practices to navigate successfully.
Like many practices, we are struggling with MIPS. Our current penalty is tied largely to cost measures that feel incredibly difficult for us to influence or even fully understand. We participate in our local hospital system’s Community Connect EPIC platform, which means we do not have full control over reporting parameters or access to the detailed data analytics larger organizations often rely on to manage performance metrics. We are expected to improve scores and reduce costs, but we are often operating without the tools needed to effectively monitor or respond to the data driving those penalties.
At the same time, the reality of our patient population directly impacts those cost measures. More than half of our patients are Medicare beneficiaries, and many also carry Medicaid as secondary insurance. These are patients who often have limited support systems at home, transportation challenges, financial hardships, and complex medical needs. After surgery, many require skilled nursing rehabilitation instead of being discharged home. Others need longer in-home care because outpatient therapy access is limited or transportation is unreliable.
Those factors increase costs, but they are also the realities of caring for vulnerable patient populations in our communities. As administrators, we understand the importance of cost containment and accountability. But there is a growing disconnect when payment models and performance metrics fail to adequately account for the social and logistical barriers our patients face every day.
Our practice is also participating in the CMMI TEAMS model because our affiliated hospital system was mandated into the program. While the goals of coordinated care and value-based reimbursement may sound reasonable on paper, implementation has created significant administrative burden for small practices like ours.
We now attend meetings with the hospital twice each month related to the program. The hospital has teams dedicated to population health, analytics, care coordination, compliance, and patient monitoring. We do not. We are a practice of fewer than 20 employees trying to manage the same expectations with a fraction of the resources.
We do not have our own physical therapy department. We do not have nurse navigators. We do not have sophisticated remote patient monitoring software. We are trying to compete in healthcare models that increasingly reward infrastructure and scale, while independent practices are expected to somehow absorb the workload without the staffing or capital to support it.
At times, it feels as though independent medicine is slowly being squeezed out of existence.
Like many private practices, we have explored alternative ancillary services and revenue streams to offset continuing reimbursement reductions. Yet even there, we face difficult decisions. Some products and services may provide excellent clinical outcomes and reimbursement opportunities, but increased utilization can negatively impact cost benchmarks under these payment models. In some cases, practices are forced to weigh what may clinically benefit patients against how those decisions could financially affect future reimbursement performance.
That is an incredibly uncomfortable place to be as a healthcare leader.
There are moments when I question whether I know enough to lead our practice through this environment. My formal healthcare administration education did not prepare me for the complexity of federal payment policy, bundled payment models, quality scoring methodologies, or the constant evolution of Medicare regulations. Much of it still feels like learning an entirely new language.
When I sit with peers involved in advocacy work, I often feel intimidated. Some seem to effortlessly understand the details of legislation, reimbursement formulas, and regulatory policy. Meanwhile, I am still trying to connect the dots between a proposed rule change and how it may ultimately impact our staff, our surgeons, our patients, and our survival as an independent practice.
But I also know this: if administrators like me do not become involved, our voices will be missing from the conversation.
That is why I joined the AAOE Advocacy Council.
Not because I have all the answers. Not because I consider myself a policy expert. But because I realized that remaining silent was no longer an option. Independent orthopaedic practices bring tremendous value to their communities. We provide accessible care, long-standing patient relationships, and local healthcare stability. Yet too often, policy discussions are shaped by organizations with vastly different resources and operational realities.
We need more independent practice administrators willing to step into advocacy, even when it feels intimidating.
We need administrators willing to say that quality care cannot always be measured cleanly in spreadsheets and cost formulas. We need people willing to explain how social determinants of health impact orthopaedic outcomes. We need leaders willing to advocate for policies that recognize the challenges facing small practices before more of them disappear through hospital acquisition or private equity consolidation.
I do not know exactly what the future of independent orthopaedics will look like. Some days, I genuinely fear failing the practice I have been entrusted to help lead. I fear making the wrong operational decisions in an environment where the rules constantly change. I fear that despite our best efforts, maintaining independence may eventually become impossible.
But I also know that giving up is not an option.
Our patients still need us. Our communities still need us. And practices like ours deserve a voice in shaping the future of healthcare policy.
That is why I will keep learning. Keep asking questions. Keep showing up to advocacy meetings even when I feel out of my depth. Because if independent practices are going to survive the future of healthcare, we cannot afford to sit on the sidelines while others decide it for us.