Medicare is ignoring the real cost of joint replacements — and that’s a primary care problem too

The Centers for Medicare & Medicaid Services (CMS) just proposed another round of cuts to what Medicare pays for joint replacement surgery. Patients and the physicians taking care of them afterward are the ones who'll end up covering the difference.

The proposed 2027 Medicare Physician Fee Schedule would cut payment for hip and knee replacement payments by roughly 20%, on top of a previous payment cut that already took effect. At this level, some surgeons won't have much of a choice; they'll have to limit how many Medicare patients they take on because the reimbursement doesn't cover the overhead anymore. That hits rural areas hardest. Rural patients already have fewer surgeons to pick from, and if their surgeon starts turning Medicare patients away, there usually isn't a second option nearby.

The 20% reduction rule also makes it more challenging for a surgeon's own office to see a patient the same day for an office visit plus a procedure. If the same physician, or another physician in the same practice, bills a separately identifiable office visit the same day as a procedure, the lower-valued service would be paid at half rate. So, a surgeon's team ends up penalized for exactly the kind of same-day access that represents efficient care.

The primary care physician's share of an orthopedic problem

A joint replacement is an hour of actual surgery, with hours of consultation and planning beforehand, and then thousands of hours of recovery after. Whether that patient avoids a revision, stays off opioids, and gets back to their normal life gets decided in the four to six weeks before and the 12 weeks after surgery.

A lot of that work ends up on primary care's desk. Patients go back to their own doctor when they can't get an appointment with the surgeon fast enough regarding a medication question, a wound that looks off, pain that isn't controlled, or something that doesn't seem orthopedic at all at first, such as a diabetes or blood pressure issue that flares up during recovery. And specialty practices already absorbing their own cuts usually can't hire the extra staff who'd normally handle that overflow, so it falls on whoever the patient can actually get in front of.

When a patient can't reach anyone on the surgical side, the emergency room (ER) is often where they end up instead. Close to 1 in 10 patients with a total joint replacement nationally presents to the ER within 90 days of surgery; one hospital's own data put it closer to 15%. Medicare doesn't build any of that – the calls, the wound checks, the ER trips – into what it pays for the surgery. And under the new proposal, that work is even more likely to get reimbursed at half rate.

Where the gap shows up

You can see the gap the moment you compare what orthopedic practices already track against what Medicare actually pays. Surgeons track range of motion, pain scores, how fast a patient tapers off opioids — the same measures used in published outcomes research. Medicare doesn't touch any of it. The fee schedule pays for the procedure. Whether or not the patient sees improvement from surgery isn't really part of the equation.

Close to half of patients with a total knee replacement still haven't regained 110 degrees of knee flexion, roughly what it takes to comfortably get off a chair or a toilet, four months out from surgery. That's around 450,000 Americans a year still dealing with basic mobility problems long after Medicare has already closed the book on their surgery.

It's not only mobility either. Poor sleep is one of the most common complaints I hear from patients after this surgery. Atrial fibrillation and poor glucose control show up more than people expect during recovery too. Patients dealing with either one usually call their primary care doctor, not their surgeon. That's more recovery work nobody's accounting for.

The looming opioid problem

Opioid dependence is probably the clearest risk here. Patients undergoing joint replacement are commonly sent home with more than 100 tablets, averaging around 110 oxycodone 5 mg pills. A study at one academic medical center, published in JAAOS: Global Research and Reviews, found surgeons believed they were prescribing around 30 pills when the actual number was much higher. At that level, published research puts the risk of new persistent opioid use around 8.5%, climbing to nearly 17% once you're above 160 tablets. When a patient can't reach their surgeon for pain management, they'll call their primary care doctor instead, increasing the likelihood of opioid dependency.

What CMS should measure instead

CMS has signaled it wants to pay for coordination and long-term outcomes rather than volume, and its recent moves back that up. The old bundled-payment model for joint replacement, Comprehensive Care for Joint Replacement, wrapped up in December 2024, and CMS has already finalized a mandatory nationwide successor, CJR-X, short for Comprehensive Care for Joint Replacement Expanded, which holds hospitals accountable for both cost and quality across a full 90-day episode starting in 2028. That's CMS quietly admitting the recovery period deserves its own accounting, not just the surgery itself.

If that's really the direction things are heading, it shouldn't stop at one bundled program. Track whether patients regain range of motion on schedule. Track whether opioid use tapers the way it's supposed to. Track whether a complication gets caught early instead of turning into a readmission. None of that is complicated to measure. It just isn't priced into the fee-for-service system most physicians and patients are actually operating under.

And the financial gap here isn't small. Since 2000, inflation-adjusted Medicare reimbursement for hip and knee replacement has dropped somewhere between 37% and 41%, while the office operating costs have doubled in that same time frame.

Medicare is playing a dangerous game by cutting reimbursement to a point where patient care is being compromised. New technology and operating room efficiency have driven real savings, but instead of putting that back into recovery, Medicare keeps pulling resources out. The thousands of hours that go into preparing for and recovering from surgery matter just as much as the time spent in the operating room, maybe more.

The current Medicare Physician Fee Schedule doesn't pay for that preparation and recovery work, and the 2027 proposal would cut payment for these procedures even further. Another round of cuts just pushes surgeons to pull back on post-op support, and primary care and emergency physicians are left cleaning up after a surgery they didn't perform, for a fee schedule that never accounted for their time to begin with. Until Medicare finds a way to appropriately reimburse for that recovery window and support the physicians, surgeons and primary care doctors alike who carry the burden, another round of cuts will only make the problem worse. Instead of penalizing surgeons, maybe CMS should focus on incentivizing them to meet metrics that matter to patients.

Andrew Wickline, M.D., FAAOS, is chief medical officer at Kinomatic and a board-certified orthopedic surgeon specializing in total hip and total knee replacement. In more than 17 years of practice, he has built deep experience in computer navigation and robotic surgery, muscle-sparing approaches including anterior hip replacement and tourniquet-free knee replacement.