In Episode 46 of The Joint Replacement Podcast, I sat down with P. Maxwell Courtney, MD, Division Chief of Adult Reconstruction at Rothman Orthopaedics and Chair of the American Association of Hip and Knee Surgeons (AAHKS) Advocacy Committee. This episode was a particularly meaningful one for me because Max was my chief resident during my orthopedic residency at the University of Pennsylvania. He was someone I looked up to early in my career as an exceptionally talented surgeon, researcher, and leader. AAHKS currently lists Dr. Courtney as Chair of its Advocacy Committee.
Our conversation began with Max’s path into orthopedic surgery, research, mentorship, and adult reconstruction. But the heart of the episode focused on an issue that may have major implications for both surgeons and patients: the proposed 2027 Medicare cuts to total hip and knee replacement.
What is Medicare proposing?
In July 2026, the Centers for Medicare & Medicaid Services released its proposed 2027 Medicare Physician Fee Schedule. The rule is not yet final, and CMS is accepting public comments through September 14, 2026.
AAHKS has characterized the proposal as roughly a 20% reduction in Medicare reimbursement for primary total hip and total knee replacement and has formally urged CMS to withdraw the proposed reductions to CPT codes 27130 and 27447.
That proposed cut comes on top of previous reductions. According to AAHKS, total joint arthroplasty reimbursement had already been reduced substantially in 2026, making the proposed 2027 changes particularly concerning for surgeons who care for large Medicare populations.
Importantly, the Medicare Physician Fee Schedule does not simply assign a dollar amount to an operation. Physician payment incorporates work relative value units, practice expense, malpractice expense, geographic adjustments, and a conversion factor. CMS has historically relied heavily on physician surveys and recommendations from the AMA Relative Value Scale Update Committee, commonly known as the RUC, when determining how physician work is valued.
Have joint replacement surgeons become victims of their own success?
One of the most interesting parts of my conversation with Max was the paradox created by the remarkable progress in joint replacement over the past decade.
When we were residents, many patients remained in the hospital for several days after hip or knee replacement. Postoperative care frequently involved general anesthesia, narcotic patient controlled analgesia, anticoagulation with medications such as Lovenox, blood transfusions, rehabilitation facilities, and sometimes continuous passive motion machines.
Modern joint replacement looks very different.
Research performed by orthopedic surgeons helped drive the widespread adoption of tranexamic acid, aspirin based thromboprophylaxis in appropriate patients, multimodal pain management, regional anesthesia, rapid recovery pathways, and outpatient joint replacement. These advances have helped shorten hospital stays and improve the overall patient experience.
That success may now be influencing how Medicare values the procedure.
As Max explained, the increasing shift of hip and knee replacement into the outpatient setting helped trigger another review of these procedures. Traditional reimbursement calculations included physician work associated with hospital rounds and postoperative visits. As length of stay has fallen, some of those easily measured encounters have disappeared from the formula.
But the patient did not disappear.
The work has changed.
Modern postoperative care increasingly includes telephone calls, electronic messages, wound photographs, medication management, virtual communication, nursing triage, and rapid intervention designed to prevent unnecessary emergency department visits and hospital readmissions. Max described research from his group suggesting that patients may contact the surgical team multiple times during the postoperative episode, yet much of that interaction may not be adequately represented in traditional valuation methods.
That led to one of my favorite questions of the episode: if efficiency causes reimbursement to fall, should surgeons simply go back to practicing joint replacement like it was performed 20 years ago?
Of course not.
Better recovery, shorter hospitalization, and safer care are good for patients. But a reimbursement system should ideally reward improvements in value rather than create a financial penalty for achieving them.
Physician payment versus facility payment
Another striking issue is the difference between how Medicare updates payments to hospitals and surgery centers compared with physicians.
CMS has proposed increases to hospital outpatient and ambulatory surgery center payment rates for 2027. AAHKS has specifically highlighted the contrast between increasing facility reimbursement and the proposed reduction in surgeon reimbursement for arthroplasty.
Max emphasized during our conversation that this should not be viewed as surgeons versus hospitals. Hospitals, nurses, operating room staff, and surgery centers are also facing increasing labor and operating costs.
The question is why the professional component of care is being treated so differently.
The surgeon is responsible not only for performing the operation but also for patient selection, preoperative planning, management of complications, and postoperative care throughout the global period. If physician reimbursement continues to decline while the cost of running a practice increases, the concern becomes less about any individual procedure payment and more about whether certain practice models remain economically sustainable.
Could Medicare cuts eventually affect access to joint replacement?
This is where reimbursement becomes a patient issue.
Max raised the possibility that continued reductions could eventually lead some surgeons or practices to limit the number of Medicare patients they accept. Independent practices may be particularly sensitive to declining reimbursement because they must directly absorb the costs of staff, malpractice insurance, information technology, rent, and other overhead.
If fewer surgeons are willing or financially able to provide elective joint replacement to Medicare beneficiaries, the downstream effect could be longer wait times and reduced access to care.
There is also a broader concern about consolidation. Financial pressure on independent practices can accelerate acquisition by hospitals, large health systems, or other corporate entities. Whatever one thinks about different practice structures, preserving competition and multiple viable models of physician practice is important for the healthcare system.
Taking the argument to Washington
This debate has moved beyond medical society meetings.
In early September, Dr. Courtney joined AAHKS leaders in Washington, DC, for meetings with nearly two dozen members of Congress and congressional staff, along with representatives from HHS and CMS. The group specifically discussed the potential effects of the proposed arthroplasty cuts on practices and Medicare beneficiaries. Representative Greg Murphy, MD, agreed to lead a congressional letter asking CMS to pause the proposed reductions while a longer term solution to arthroplasty payment is developed.
Max made an important distinction during our discussion. Conversations with CMS are often highly technical and focus on physician time, RVUs, comparison codes, postoperative visits, and methodology. Conversations with legislators are different.
For lawmakers, the more understandable question is what happens to their constituents.
Can a 75 year old with severe hip arthritis still find a surgeon?
Will she wait three weeks for an appointment or six months?
Will surgeons continue accepting Medicare?
Those questions may ultimately be more powerful than any debate over the precise number of RVUs assigned to an operation.
Where does this go from here?
I asked Max to predict what happens when the final 2027 Medicare Physician Fee Schedule is released.
He does not expect the entire proposed reduction to survive unchanged. His best estimate was that some portion of the cut could be mitigated, potentially leaving something closer to a 10% reduction, although he emphasized that he hopes CMS ultimately withdraws the cuts altogether.
As of this writing, however, the proposal remains just that: a proposal.
The larger debate will continue even after the 2027 rule is finalized. Medicine has changed dramatically, particularly in procedures such as joint replacement where care has moved out of the hospital and into outpatient and increasingly digital environments. A payment system built around minutes, physical encounters, and historical patterns of care may struggle to capture that evolution accurately.
The challenge is creating a system that rewards efficiency without confusing efficiency with less physician work or less physician responsibility.
Hip and knee replacement remain among the most successful operations we perform. The goal should be to continue making these procedures safer, more efficient, and more accessible while ensuring that the surgeons and healthcare teams providing that care can sustainably continue doing so.
🎙️ Episode 46 of The Joint Replacement Podcast with P. Maxwell Courtney, MD is available now on YouTube, Spotify, and all major podcast platforms.
References
- Centers for Medicare & Medicaid Services. Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule. July 14, 2026. CMS 2027 Physician Fee Schedule Proposed Rule
- American Association of Hip and Knee Surgeons. AAHKS Submits First CMS MPFS Comment Letter. August 28, 2026. AAHKS comment on proposed arthroplasty cuts
- American Association of Hip and Knee Surgeons. AAHKS Leaders Meet with HHS, CMS and Congress. September 4, 2026. AAHKS Washington advocacy update
- American Association of Hip and Knee Surgeons. AAHKS Submits Outpatient and ASC Proposed Rule Comments to CMS. September 4, 2026. AAHKS OPPS and ASC comments
- Centers for Medicare & Medicaid Services. Calendar Year 2027 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Proposed Rule. July 2, 2026. CMS 2027 OPPS and ASC Proposed Rule