What if the future of joint replacement is not simply about performing a better operation, but about building a better healthcare system around the patient?
In Episode #37 of The Joint Replacement Podcast, I sit down with Kevin Bozic, MD, MBA, an orthopedic surgeon specializing in hip and knee replacement, Chair of the Department of Surgery and Perioperative Care at Dell Medical School at the University of Texas at Austin, and former President of the American Academy of Orthopaedic Surgeons. Dr. Bozic has also become a leading voice in value-based healthcare, patient-reported outcomes, payment reform, and redesigning the delivery of musculoskeletal care.
Our conversation explores an important question for the future of orthopedics: How do we move from a healthcare system that rewards the delivery of procedures to one that rewards better health?
What Does “Value” in Healthcare Really Mean?
“Value-based healthcare” has become a common phrase, but Dr. Bozic argues that its original meaning is often misunderstood.
His interest in the subject dates back to Harvard Business School, where he met Michael Porter, whose work on value in healthcare ultimately changed the trajectory of Dr. Bozic’s career.
As Dr. Bozic explains in the episode, value is not simply synonymous with reducing healthcare spending. The framework instead focuses on the health outcomes that matter to patients relative to the resources required to achieve them. If the patient’s health does not improve, simply delivering care more cheaply does not necessarily create greater value.
That distinction has enormous implications for hip and knee replacement.
Measuring What Actually Matters to Patients
Traditionally, orthopedic surgeons have been very good at measuring surgical outcomes: complications, infections, readmissions, implant survival, radiographs, and revision rates.
Those measures remain important. But they do not completely answer the question that matters most to a patient:
Did treatment make my life better?
Dr. Bozic argues that practices need to rigorously measure outcomes such as pain, function, and quality of life and then incorporate those patient-reported outcomes into clinical decision-making. In his practice, these measurements can influence triage, follow-up, treatment decisions, and which members of the multidisciplinary team become involved in a patient’s care.
This shifts the focus from whether a procedure was successfully completed to whether treatment actually accomplished what the patient hoped it would accomplish.
Moving Beyond “Surgery or Sorry”
One of the most memorable concepts from our conversation is Dr. Bozic’s description of the traditional orthopedic model as offering patients two options: “surgery or sorry.”
Many patients with hip or knee arthritis are not yet ready for joint replacement. Others may have obesity, anxiety, depression, deconditioning, social challenges, or other factors that could influence their symptoms and eventual outcome.
Instead of simply telling those patients to return when they are ready for surgery, Dr. Bozic’s integrated model brings additional expertise into the musculoskeletal care team. This can include physical therapy, weight management, behavioral health, and other services designed to address the patient’s overall needs.
The underlying idea is simple: organize healthcare around the condition being treated, rather than around the specialty or training of the physician.
Physical Therapy Before and After Joint Replacement
We also discuss the evolving role of physical therapy.
Dr. Bozic explains that his practice does not routinely recommend postoperative physical therapy for hip replacement patients. Knee replacement patients generally begin with a physical therapist but are encouraged to transition toward a self-directed program when appropriate.
Where physical therapy plays an especially important role in his model is before surgery. Many patients presenting with hip or knee arthritis receive an individualized home exercise program rather than immediately being directed toward an operation.
This can also help patients become active participants in their own treatment.
Patient Activation: Preparing for a Better Outcome
That leads to another fascinating part of the conversation: patient activation.
Dr. Bozic describes a spectrum ranging from a patient who essentially approaches healthcare as “I’m broken—fix me” to a patient who has taken meaningful steps to optimize his or her health and now needs additional medical or surgical help.
Exercise, smoking cessation, weight management, and other forms of health optimization may therefore serve another important purpose: they engage patients in their recovery before an operation ever occurs.
As Dr. Bozic explains, the goal is not necessarily perfection. A patient who demonstrates meaningful engagement and progress may be very different from someone who remains completely disengaged from the process.
Behavioral Health Is Part of Musculoskeletal Health
Pain does not exist in isolation.
Anxiety, depression, resiliency, social circumstances, and other factors can influence how patients experience musculoskeletal disease and how they recover from treatment.
Dr. Bozic’s practice screens patients for anxiety and depression and can incorporate behavioral-health-trained social workers into the treatment team. Importantly, he describes this not as telling patients that their arthritis is “in their head,” but as recognizing that mental and physical health can interact in meaningful ways.
It is a more comprehensive approach to treating the person rather than simply treating an X-ray.
How Payment Models Influence Medical Care
The second half of our conversation turns toward one of Dr. Bozic’s major areas of expertise: healthcare payment reform.
His central argument is that how healthcare is paid for inevitably influences how healthcare is delivered.
Fee-for-service medicine rewards the delivery of individual services. Procedure-based bundled payments encourage providers to coordinate and improve the efficiency of an episode of care. Dr. Bozic points to the dramatic reduction in inpatient post-acute care following hip and knee replacement as one example of how changing incentives helped reshape practice patterns.
But procedure-based bundles still begin with a procedure.
That creates an important limitation: a healthcare system can potentially become extremely efficient at delivering an operation without adequately addressing whether that operation was the right treatment for that particular patient.
From Procedure-Based Care to Condition-Based Care
Dr. Bozic believes the next evolution is moving further upstream.
Rather than bundling payment around a knee replacement, imagine organizing care around knee arthritis itself.
His practice has worked with a model that prospectively pays for management of musculoskeletal conditions while holding the team accountable for patient-reported outcomes. That structure can give clinicians greater flexibility to use physical therapy, behavioral health, weight management, injections, surgery, or other interventions according to what is most likely to improve the patient’s health.
Importantly, Dr. Bozic distinguishes this model from traditional capitation. Fee-for-service can incentivize overutilization, while pure capitation can create incentives for underutilization. A condition-based episodic model attempts to align payment with achieving better patient outcomes while preserving access to surgery when surgery is the appropriate treatment.
The Economics of Modern Joint Replacement
We also discuss the growing tension surrounding reimbursement for joint replacement.
Over the past several decades, surgeons and health systems have introduced multimodal pain management, preoperative optimization, shorter hospital stays, outpatient surgery, and increasingly efficient perioperative pathways. Yet in a fee-for-service system, becoming more efficient can ultimately contribute to downward pressure on reimbursement.
Dr. Bozic argues that this creates a fundamental misalignment: innovation that allows clinicians to deliver better and more efficient care should ideally be rewarded rather than discouraged.
The broader lesson extends well beyond orthopedics. Payment models are not simply financial mechanisms—they can shape clinical behavior and the structure of healthcare itself.
How a Joint Replacement Expert Chose His Own Surgeon
Perhaps the most valuable portion of the episode for patients comes at the end.
Dr. Bozic has undergone three joint replacements himself, giving him the unusual perspective of being both a joint replacement surgeon and a patient.
When he recently needed hip replacement, he did not choose his surgeon based primarily on a particular implant or surgical approach.
Instead, he focused on the surgeon.
His priorities included experience, surgical volume, outcomes, the quality and experience of the facility, and—critically—the ability to trust the surgeon he selected. Once he chose that surgeon, he was comfortable allowing the surgeon to use the approach and implants with which that surgeon achieved the best results.
Research broadly supports an association between procedure volume and at least some outcomes following total joint arthroplasty, although the strength of that relationship varies by procedure and outcome. Systematic reviews have reported trends toward improved outcomes with greater surgeon volume in both hip and knee replacement, while higher hospital TKA volume has been associated with lower mortality and readmission rates in pooled analyses. [1–3]
For patients choosing a surgeon, the message from our discussion is therefore refreshingly straightforward:
Choose an experienced surgeon with good outcomes, at an experienced facility, whom you trust—and then allow that surgeon to do what they do best.
Rethinking the Future of Joint Replacement
Technology will undoubtedly continue to transform hip and knee replacement. Robotics, artificial intelligence, advanced imaging, new implants, and data analytics all have the potential to improve what happens in the operating room.
But this conversation with Dr. Bozic highlights another equally important frontier.
The future of joint replacement may depend on our ability to better identify who needs surgery, when they need it, what outcomes matter to them, what can be improved before surgery, and how the entire healthcare system can be aligned around improving their health.
That is a much bigger challenge than simply performing an operation more efficiently.
It may also be one of the greatest opportunities in modern orthopedics.
Watch or listen to Episode #37 of The Joint Replacement Podcast for the full conversation with Kevin Bozic, MD, MBA.
This article and podcast are intended for educational purposes only and do not constitute medical advice. Treatment decisions should be made in consultation with a qualified healthcare professional.
References
- Malik AT, Jain N, Scharschmidt TJ, Li M, Glassman AH, Khan SN. Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review. Journal of Arthroplasty. 2018;33(10):3329-3342. doi:10.1016/j.arth.2018.05.040.
- Lau RL, Perruccio AV, Gandhi R, Mahomed NN. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskeletal Disorders. 2012;13:250. doi:10.1186/1471-2474-13-250.
- Kugler CM, Goossen K, Rombey T, et al. Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2022;30(8):2862-2877. doi:10.1007/s00167-021-06692-8.
- Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. Journal of Bone and Joint Surgery American. 2004;86(9):1909-1916. doi:10.2106/00004623-200409000-00008.