Musculoskeletal patient care has shifted from hospital-based to outpatient sites of service.(1–3) Although the COVID-19 pandemic accelerated the change, care for musculoskeletal cases has been moving outside the hospital setting, for years, driven by the technology and skill needed to perform minimally invasive surgery. Other contributing factors have been anesthesia advances; physician ownership through regulatory allowance; CMS adding reimbursement codes permitting more cases to move from the hospital setting to the outpatient setting; high rates of patient satisfaction; increased efficiency; and decreased complications.(1–10)
Musculoskeletal care is likely the canary in the coal mine for many other specialties, such as gastroenterology, cardiology, vascular surgery, and interventional radiology, which also can deliver care outside hospitals. There is a historic precedent. Renal dialysis was an inpatient procedure until outpatient models eclipsed the inpatient market.(11) This revolutionized the convenience of care and improved value. The private equity and venture capital investments that were the engines of change are now investing in musculoskeletal medicine to achieve the same goal.
Without innovative solutions, health systems face financial failure if they do not mitigate this outflow of patient care revenue. Musculoskeletal care accounts for one-sixth of all healthcare costs.(12) For example, the direct and indirect cost of back and neck pain, in the U.S., is $134.5 billion, and other musculoskeletal conditions cost $129.8 billion. It is one of the fastest-growing segments of procedure-based medicine, propelled by our aging and active population. By 2030, the growth in musculoskeletal care will be greater than 25%, led by a three- to five-fold increase in joint replacement surgery over the next seven years.(12,13)
The economic burden of musculoskeletal care is greater than that of many other chronic conditions. These conditions affect the entire lifespan, as opposed to many disease processes that develop later in life. Many of these patients are in our labor market; therefore the loss of workdays—more than 250 million days—has an additional impact on the economy. Patients with musculoskeletal conditions have higher private insurance to public insurance ratios.(7) The financial losses to hospital systems will be significant unless there is a change in their strategy and tactics.
Orthopedic surgery has moved over 70% of cases to ambulatory, outpatient facilities. In 1994, 28% of procedures were outpatient, reaching 40% in 2005 and 60% by 2011, and projected to reach 68% by the mid-2020s.(3,14,15) A study of six common orthopedic procedures found that 34% were performed in ambulatory surgery centers (ASCs) in 2018.(16)
Hospitals have created an alternative to ASCs—hospital outpatient departments (HOPDs). These can be attached to the main hospital or as much as 35 miles away from it. HOPDs perform the same kinds of operations as ASCs, yet have double the average cost, higher implant costs, and higher patient out-of-pocket costs. The COVID-19 pandemic pushed more cases to alternative sites of care outside hospitals, especially outpatient-based facilities.(16–18)
Hospital systems have attempted to block these outflows, either by purchasing physician practices or by following hiring patterns that focus on HOPD and inpatient services.(3) Continuing these practices will not prove productive, because the reimbursement model is decreasing with payer and employer momentum toward the outpatient site of service and physician alignment with ownership in ASCs. Most health systems have fully committed to fee-for-service payment models. They have been frozen in the status quo, which will limit growth versus outpatient-based, innovative business processes around value-based care and technology that increases patient access to care.
For future success, hospital systems should create an independent, integrated musculoskeletal program consisting of affiliated outpatient centers, home care, and virtual care, partially financed by partnerships with innovative private capital entrepreneurs. This program will focus on (1) access to patient-centric care; (2) seamless navigation of care; and (3) value of care. By shifting patients to the most cost-efficient site of care producing equivalent outcomes, value and margins will improve. Partnerships of health systems, independently run joint venture outpatient facilities, and private capital will integrate horizontal and vertical healthcare delivery through technology platforms. Collaboration will dominate markets by widening the accessibility for patients and decreasing cost for payers. This integrated musculoskeletal program also must adopt cost accounting that is site-specific, rather than the current ruinous cost averaging that distributes the hospital’s costs to this new venture.
Health systems alone have not changed and likely cannot change their business plans to incorporate the changes we propose. They have a risk-averse culture, lack the expertise, have no history of joining forces with other health systems or private capital, rely on past payment models, and are unfamiliar with the urgency of nimble market adjustments.
The Problem & Opportunity
Many health systems with fee-for-service payment models operate within a silo system for each musculoskeletal service. Each department functions independently in terms of scheduling, there is limited communication between providers, and each area generates its own bill. This has deleterious effects on the patient care journey, and patients often receive multiple bills from the same health system. Energized by fee-for-service payment, silos have created inefficiency and led to prohibitive costs within large hospitals and health systems. Disconnected accounting/finance, patient access and navigation challenges, and decreased provider efficiency have multiplied the problems. Payers, patients, and healthcare professionals are all dissatisfied.
The push from payers and medical economists to bring down healthcare costs often begins with a value-based ratio of cost and outcomes, rather than fee-for-service reimbursement.
The risks to static health systems are inexorably approaching. First, all insurance contracts and hospital fees were published as of January 1, 2021. Although many health systems have delayed publishing, efforts are underway to enforce this regulation. This requires the systems to justify fees and value, defined as outcome and cost. The push from payers and medical economists to bring down healthcare costs often begins with a value-based ratio of cost and outcomes, rather than fee-for-service reimbursement. Second, the patient has become the consumer, or customer.(13,14) Patient access to care and satisfaction with that care and its outcomes are their definition of value. Patients are aware of out-of-pocket costs and care delivery options. Third, the cost structure to deliver musculoskeletal care in a hospital is higher than that in an ambulatory facility. Hospitals depend on revenue generated by operating rooms, radiology, laboratory, and physical therapy. Fourth, musculoskeletal care is one of the fastest growing in terms of patient volume.
Payers reject hospital-based fee schedules for procedures that can be performed in outpatient settings. Regulations specific to hospitals cripple their competitiveness. There are 629 discrete regulatory requirements, which cost, on average, $1200 per patient admitted to the hospital.(15) Many orthopedic surgery procedures are reimbursed equally regardless of the site of care, although the costs are greater in hospitals.
There is a shift from fee-for-service to value-based care. The Affordable Care Act led to a change in customer behavior, based on accessibility, affordability, and cost structures. Employers and patients are now retail customers, and, therefore, the decision-makers.(13,14) Many health systems have chosen to continue to pursue fee-based reimbursement, creating inefficiencies through fragmented care.
Role of Cost Accounting
Accurate cost accounting is critical to measuring value. Health systems are at a disadvantage currently through inpatient fee-for-service revenue models. This has an inherent risk for four reasons:
Hospital systems often cost-average for all surgical procedures. Implant costs often are divided by the number of cases without attribution by type of procedure. Cases with low implant costs have higher margins than cases with higher implant costs, which create lower margins. This raises the cost per case of less expensive implant operations, which could be performed in an outpatient facility, and lowers the cost average of complex surgeries that belong in a hospital-based site of care.
A reimbursement blind spot occurs without understanding the true cost of each procedure. For instance, by cost averaging, complex cases may be more expensive to the system than they appear, and payment too low.
By underestimating the cost of complex procedures and not recognizing the value of improved outcomes, including fewer expensive complications for complex cases, hospital systems cannot negotiate improved rates for complex cases.
By moving appropriate cases to outpatient sites of service, the scale will decrease overhead costs, and lead to improved revenue and margins.
Real-time cost accounting with independent operational management allows better financial decisions for each site of service. For instance, if knee arthroscopy is being reimbursed equally whether inpatient or outpatient, sending those cases to the outpatient facility has the advantage of higher volume, efficiency, and reduced cost.(4,5,12) In addition, surgical teams doing a higher volume of cases have shown better outcomes.(6) Keeping measurements on outcomes and layering them on cost will give value metrics that address patient and payer concerns. This will improve value, driving payers to the most cost-effective sites of care.
The Influence of Private Capital
Private equity and venture capital have invested heavily in the musculoskeletal space.(19–22) Venture capital musculoskeletal funding grew six-fold between 2020 ($236 million) and 2021 ($1.4 billion). Private equity investment in healthcare was $100 billion in 2018.(23) Private equity has aggregated practices, physicians, and facilities into groups with the size to negotiate higher reimbursement, decrease the cost of supplies, and maximize efficiency. Private equity–backed emergency care businesses now account for 40% of U.S. hospitals’ emergency department physician coverage.(24)
Venture capital investment has created innovations in care delivery and developed treatment solutions through virtual and independent delivery systems. Innovative startups Hinge Health and Sword Health created nonoperative management by diagnoses such as back pain by going directly to the employers and patients. Each completed multiple raises of over $900 million.(19) Vori raised $53 million to provide the spectrum of value-based musculoskeletal care.(21) Digital therapeutic companies’ values have risen 40% over seven years.(19,20) These companies operate independently from health systems, often offering patients who previously would have had treatment in health systems a different treatment option, therefore drawing revenue away. There are examples of health systems—notably Kaiser Permanente and Intermountain Healthcare—partnering with or investing in privately backed companies.(23,25–28) These innovative companies have found focus and met the market needs of increasing patient access, ease of navigation, and utilizing technology to impact the delivery of care outside the hospital-based site of care and cost structure.
The COVID-19 pandemic shifted the paradigm of care delivery.(29) Elective and nonurgent procedures and surgery were canceled, and hospital beds were fully occupied. Many procedures for musculoskeletal conditions are elective. These patients and their needs were not met in hospitals, which created an opening for virtual and outpatient solutions, including the development, delivery, implementation, and acceptance of widened parameters of care delivery outside the traditional health system setting. Once adoption began and the technological learning curve passed, providers, patients, and payers were comfortable under a relaxed regulatory environment.(30)
A bifurcation occurred once the pandemic restrictions lessened. Health system and hospital-based providers returned to in-person clinics and either stopped or decreased virtual patient care. Many of these providers were not interested in the hybrid or virtual model,(26) but neither were large populations of patients who craved returning to interpersonal relationships with their doctors. Relaxation of restrictive state regulatory rules during the COVID-19 crisis increased accessibility.(29,30) Some patients, however, were reluctant to return to hospital settings. Many of the new technology-based delivery options saw the proven need, value, and desire of patients resulting in a transformational opportunity. Private capital provided options focused on prevention, access, and navigation of care at a lower price point. Yet, complex patients require inpatient care. With large populations being vaccinated, the pandemic receded and demand for musculoskeletal care increased. Simultaneously, patients shifted to digital, home-based, outpatient, and now venture-funded hybrid facilities and platforms.
Venture capital–backed innovation companies often are launched to solve a clinical or process-related issue within healthcare.
Private capital has risks as well in their current model. Venture capital–backed innovation companies and private equity–backed businesses have challenges in entering the U.S. healthcare marketplace. These include policy shifts, regulatory risk, physician support, consumer advocacy challenges, and extraordinarily long contracting schedules in health systems. They have found a home in easy-to-use, independent, outpatient facilities.
Venture capital–backed innovation companies often are launched to solve a clinical or process-related issue within healthcare. These companies remain viable about 10% of the time.(31,32) Start-up companies face the challenge of driving revenue versus their consumption of capital. It can take an extended period to establish and prove an area of impact. Contracting with hospitals is an arduous process that requires security and data compliance, regulatory compliance, technological integration, and cultural acceptance by patients and providers. It is critical that the healthcare startup has the resources, skill set, and humility to understand the culture of decision-making and clinical acceptance within the health system environment. This often necessitates dislodging the health system status quo.
Private equity has challenges often related to the short-term three- to seven-year window on investments, the physician employment aspect, regulatory and policy enforcement, and the optics surrounding the typical 20% annual return in the healthcare space. Private equity investments from 2000 to 2018 totaled $833 billion over 7300 investments.(32)
This capital allocation is coming under scrutiny. Private equity staffing of emergency departments often led to the creation of invoices outside the patient’s network. These unexpected bills, known as “surprise billing,” led Congress to pass legislation to end this practice.(23,33) By focusing on the more profitable aspects of healthcare, such as the emergency departments, private equity brought unflattering attention, including a lawsuit by the New York Attorney General. The accusation is they influence the decision-making of their employed healthcare providers. Congress also has accused them of “outsized profits” for their shareholders.(23,24,33) Hospitals provided resources and personnel, which brought them unwelcome scrutiny.
Private equity–backed healthcare businesses are being questioned about the quality and safety of the care they provide.(24,34,35) Profit motives of entrepreneurs present a potential conflict of interest in patient care. Most of the criticism has focused on the increased volume, decreased resources, and personnel to achieve revenue goals and growth. The scrutiny led Congress to introduce the “Stop Wall Street Looting Act,” which increases price transparency, potentially changes tax treatment, and limits the ability to be considered passive investors.(33) Private equity–backed physician practices have a challenge with their workforce. Doctors have become increasingly vocal about the conditions of working for private equity–backed healthcare companies. There are instances of physicians being fired for questioning practices within these companies.(24) Older physicians who sell their practices to private equity–backed companies often are willing to work for only three to five more years. The next wave of physicians recruited may question the benefit of working in an environment focused on profits rather than outcomes, especially if they do not own an equity stake. This is potentially damaging to the future of the business.(34,35)
Novel Business Integration Must Be Adopted
Why should health systems and capital market-backed companies adopt a novel business integration? The answer is that it maximizes their strengths while mitigating their risks. They must incorporate the strengths of both entities to improve the patient journey, including access to care, navigation of care, and value of care. Health systems have strengths in depth and breadth of care with multiple specialties. They are best positioned to provide care in complex situations with their advanced equipment, technologies, and multiple providers. Health systems have the infrastructure in areas such as research, regulatory and policy compliance, and especially reputation, which most capital market-backed companies do not. Their risks include high inpatient charges being challenged by payers, difficult access and navigation challenges for patients, limited sites of care, and high expenses. Health systems, especially academic health centers, often are constrained with respect to raising salaries and competing with the total financial packages of capital market-based entities. The decision-making process is slower and with greater uncertainty than capital market–backed companies.
The strengths of venture capital–backed innovative companies include novel technology, singular niche focus, increased patient facilities, decreased cost of care delivery, utilization of multiple modalities and sites of care, and efficient, lean processes and organizational structure. The risks include dependence on traditionally long healthcare sales cycles; the risk of depleting capital, lacking the regulatory and security infrastructure for healthcare; and potential blind spots regarding the culture of patient care delivery.
Private equity–backed companies are able to aggregate providers to provide care in a specific sector, have capital, create efficiencies in purchasing and resource utilization, create revenue-positive care models, have multiple sites of care, and be nimble in decision-making. The risks include increasing regulatory scrutiny, cultural differences in healthcare versus their other investments, physician recruitment, and the lack of a safety net for more complex patient care issues.
The future of health systems is to partner with venture capital and private firms, but why would those firms want to partner with hospital systems? Hospitals bring community trust, understand the long contracting cycles of healthcare, and bring contracted doctors (50% of doctors are employed by hospitals). Further, hospitals have critical advantages in negotiating with government and private insurers, markedly increasing reimbursement. Hospital systems may not have strong balance sheets, but they have predictably strong revenue. All these advantages reduce capital risk, and the cost of capital.
Aligning the financial interests of health systems and innovative companies will decrease costs and increase productivity.
Health systems have expertise in areas such as patient complexity, research, regulatory and policy compliance, and especially reputation, unlike capital market–backed companies. Partnering with private equity and venture capital companies drives revenue by providing needed capital, speeds integration of novel technologies, delivers efficient outpatient facilities, and incentivizes providers. Aligning the financial interests of health systems and innovative companies will decrease costs and increase productivity. Synergistic partnerships will be transformational.
Solution
The solution is a care continuum that is site agnostic, incorporating patient/customer needs with the strengths of each provider in a seamless delivery system created through a sustainable business model. The solution merges hospitals, independent but affiliated outpatient centers, and home care, layered with telehealth, which coordinates resources, and partnerships with innovative private capital entrepreneurs focusing on 1) access to patient-centric care; 2) navigation of care delivery; and 3) value of care. The following areas will lead to success:
Create a horizontally integrated care continuum that is site-of-care agnostic.
The three sites of care—hospitals, outpatient centers, and home—will integrate seamlessly across the patient care journey.
Virtual and home care options will be available as a layer on top of in-person visits.
This horizontal integration will contribute to increased access and cost accountability and increased patient satisfaction with more access options.
Achieve maximum efficiencies by ensuring the site of service produces the ability to scale volume.
Create a vertically integrated continuum, allowing maximum access to navigation of services.
A funnel, not a silo, will reframe the delivery of care, with providers practicing at the top of their license. A greater volume of patients will be seen in multiple sites by identifying the appropriate provider for the patient, with referrals to specialists.
Navigation of this care and its associated success metrics will be done using technology to create scheduling interaction, availability, and access for follow-up treatment or studies, including surgical scheduling, laboratory testing, radiology studies, and physical therapy.
Outcomes will be collected and analyzed for care at each point along the patient journey. These data will be used for contracting, clinical research leading to improved care, and a source of revenue when sold to pharmaceutical or other healthcare industries.
Providers will have improved job satisfaction due to increased time with their patients. The navigation will be built into processes rather than providers advocating for patients’ services.
Technology that incorporates real-time provider communication along the patient care journey will be used to maximize outcomes and efficiencies of care and decrease unnecessary costs.
Create partnerships with private capital that integrate health systems and independently run outpatient facilities with home care, with innovative technology platforms merging horizontal and vertical healthcare delivery components.
Link financial data by patient, location, and complexity of care, justifying costs to payers and patients through price transparency.
Overlay access and navigation data with value data, enabling health systems and outpatient, private equity–, and venture capital–financed groups to validate their contribution and ownership, thus proving the synergistic and symbiotic nature of the relationship.
Provide incentives to physicians with the financial alignment of the new business model per regulatory constraints.
There are two opportunities for health systems to demonstrate the effectiveness of these partnerships:
Reducing the number of patients more efficiently served in outpatient facilities, which opens more opportunities for high-margin complex cases; and
Reducing the costs of building and operating unnecessary expensive facilities.
Understanding the market forces driving the clinical care continuum from hospital to outpatient to home with virtual care, presents opportunities, not obstacles. Synergistic partnerships will be transformational.
Health systems should partner or joint venture with private capital-funded, independently operated facilities to deliver inpatient and outpatient care based on an analysis of specific procedural and support costs. Payer reimbursement will shift from inpatient to outpatient fee schedules. Outpatient efficiency and lower costs of delivery will improve margins through volume scale and downstream referrals. Health systems will decrease risk and become integrated into new care models. Hospitals will open clinically necessary space and backfill with higher complexity, higher-margin, inpatient cases that are justifiable to patients and payers.
Capital-intensive health systems cannot be sustained, hire needed providers, develop outpatient facilities, and deliver innovative care without partnering with well-capitalized, savvy entrepreneurs.
Musculoskeletal services create a vertically deliverable care continuum. Current payment models such as bundled care rely on the health system’s integration of clinic visits, radiology, laboratory, procedures, and physical therapy. In a fee-based model, these are independent cost and revenue centers. Merging these allows simplification of cost analysis. Each patient’s journey of care can be analyzed to evaluate the cost. The financial reporting techniques, software, and accounting must reflect cost and revenue centers. Visionary health systems will use these data to improve outcomes and drive contracting. Combining financial accounting, bridging of services provided by multiple entities, and seamless navigation allows for the emergence of a novel model. Convergence will allow the evaluation of at-risk contracting, value-based contracting, and bundled payments. It will necessitate a clear understanding of costs at each step and financial collaboration.
Capital-intensive health systems cannot be sustained, hire needed providers, develop outpatient facilities, and deliver innovative care without partnering with well-capitalized, savvy entrepreneurs. Partnering with private equity and venture capital companies will drive revenue by providing needed capital, efficient outpatient facilities, providers, and technology companies with novel virtual care delivery. Aligning the financial interests of providers will decrease costs and increase production.
The winning model will own the patient journey independent of the site of care. The development of algorithms for access and navigation of efficient, quality care is synonymous with value. This will create an umbrella of musculoskeletal care that is tangible, achieves market dominance, is suitably marketed and branded, and will reduce patient leakage. Keeping musculoskeletal patients within health systems will serve as a referral engine driving patients to other specialties. Thus, musculoskeletal care will promote growth.
Health systems seek non-clinical revenue streams. Many have created venture funds or invested in their own physicians’ and scientists’ intellectual property.(25) Although there have been some high-profile successes, such as Children’s Hospital of Philadelphia and Spark Therapeutics, in Philadelphia, PA, many health systems are suited to invest in the area they know well, patient care.(25)The cost in time, capital, and focus of taking intellectual property from an idea to monetization demands contracting with innovative technology companies. Partnering with private capital will focus on each other’s center of excellence. For example, Intermountain Health in Salt Lake City, UT, has done this with its relationship with General Catalyst by focusing on value-based care.(27)Organizational structure and behavior will have to leverage expertise from health systems and private capital. Speed to market, nimble reactions, and care footprints will help both outpatient and inpatient sides. Integration of information technology, marketing, digital, patient journey, and cost analysis leadership teams will drive the metrics of success. Health systems must build teams where vision, strategy, and execution metrics are aligned with a willingness to alter the current business structure and cadence for innovative problem solving and real-time pivoting.(36)
Conclusion
Health systems that quickly recognize the opportunities that arise from crises such as the COVID-19 pandemic, and change their business operations in response will thrive. Innovative problem solvers within health systems will integrate and implement these opportunities through novel business models, associations, joint ventures, and licensing arrangements, with an understanding of the benefits to value, cost, and outcomes. Seamless care delivery for musculoskeletal patients will reap rewards financially and reputationally. This will drive volume into other specialties within the health system.
Health systems must be part of the solution of patient care delivery in the musculoskeletal area, as they understand complex situations based either on the diagnosis or patient health conditions. The solution is not in deciding between outpatient or inpatient care—it is integrating patient care delivered efficiently, innovatively, horizontally, and vertically, seamlessly focusing on value. Innovative health systems that incorporate and evolve will flourish; those that do not will fall behind.
Acknowledgment: The authors acknowledge the mentorship of Regina Herzlinger, the Nancy R. McPherson Professor of Business Administration at Harvard Business School.
References
Burrill S, Gerhardt W, Arora A. Hospital revenue trends: outpatient, home, virtual, and other care settings are becoming more common. Deloitte Insights; 2020. www2.deloitte.com/content/dam/insights/us/articles/5230_Outpatient-virtual-health-care-trends/DI_Outpatient-and-virtual-care-shift.pdf
Munnich EL, Parente ST. Returns to specialization: evidence from the outpatient surgery market. J Health Econ. 2018;57:147-167.
Richards, MR, Seward JA, Whaley CM. Treatment consolidation after vertical integration: evidence from outpatient procedure markets, J Health Econ. 2022;81:1-20.
Richter DL, Diduch DR. Cost comparison of outpatient versus inpatient unicompartmental knee arthroplasty. Orthop J Sports Med. 2017;5(3):1-7.
Crawford DC, Li CS, Sprague S, Bhandari M. Clinical and cost implications of inpatient versus outpatient orthopedic surgeries: a systematic review of published literature. Orthop Rev (Pavia). 2015;7:116-121.
The U.S. dialysis market size, share, and COVID-19 impact analysis, by type (hemodialysis, peritoneal dialysis), by end-user (dialysis center, home healthcare, hospital) and forecast, 2021-2028. Fortune Business Insights. 2021. www.fortunebusinessinsights.com/u-s-dialysis-services-market-105704 .
Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996-2016. JAMA. 2021;323:863-884.
Lezin N, Watkins-Castillo. The hidden impact of musculoskeletal disorders on Americans. Bone and Joint Initiative USA, 2018. www.boneandjointburden.org/docs/BMUS%20Impact%20of%20MSK%20on%20Americans%20booklet_4th%20Edition%20%282018%29.pdf .
Munnich EL, Parente ST. Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Aff (Millwood). 2014;33:764-769.
Herzlinger RE, Richman BD, Boxer RJ. How health care hurts your paycheck. The New York Times. November 2, 2016. www.nytimes.com/2016/11/02/opinion/how-health-care-hurts-your-paycheck.html .
Himmelfarb J, Vanholder R, Mehrotra R, et al. The current and future landscape of dialysis. Nat Rev Nephrol. 2020;16:573–585. https://doi.org/10.1038/s41581-020-0315-4 .
Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018;100:1455-1460.
Herzlinger RE. Pandemic caused “a lot of consumer-driven innovation”: Harvard’s Herzlinger. Bloomberg Television, October 15, 2020. www.hbs.edu/faculty/Pages/item.aspx?num=60009 .
Herzlinger RE. Let’s put customers in charge of health care. Harvard Business Review. July 2002.
Regulatory Overload Report, American Hospital Association. November 3, 2017. https://www.aha.org/guidesreports/2017-11-03-regulatory-overload-report .
Wang KY, Puvanesarajah V, Marrache M, et al. Ambulatory surgery centers versus hospital outpatient departments for orthopaedic surgeries. J Am Acad Orthop Surgery. 2022;30:207-214.
Tanaka MJ. Ambulatory surgery centers versus hospital-based outpatient departments: what’s the difference? AAOS Now. September 1, 2019. www.aaos.org/aaosnow/2019/sep/managing/managing02/ .
Iorio R. The changing economic value and leverage of arthroplasty. J Arthroplasty. 2022;37:1443-1447.
Olsen E. Digital musculoskeletal care is booming. Where does the market go from here? Mobile Health News. February 4, 2022. www.mobihealthnews.com/news/digital-musculoskeletal-care-booming-where-does-market-go-here .
Krasniansky A, Evans B, Zweig M. 2021 year-end digital health funding: seismic shifts beneath the surface. Rock Health Insights. January 10, 2022. https://rockhealth.com/insights/2021-year-end-digital-health-funding-seismic-shifts-beneath-the-surface/ .
Licholai G. Vori Health transforms back and joint pain treatment. Forbes. January 22, 2022.
Adams K. Where 13 health systems are investing their innovation dollars this year. Becker’s Health IT. July 25, 2021. www.beckershospitalreview.com/digital-transformation/where-13-health-systems-are-investing-their-innovation-dollars-this-year.html .
Gustafsson L, Seervai S, Blumenthal D. The role of private equity in driving up health care prices. Harvard Business Review. October 29, 2019.
Morgenson G. Doctor fired from ER warns about effect of for-profit firms on US healthcare. NBC News. March 28, 2022. www.nbcnews.com/health/health-care/doctor-fired-er-warns-effect-profit-firms-us-health-care-rcna19975 .
Kaiser Permanente Ventures, kpventures.com/portfolio/.
Reed T, JPM20. UPMC ventures announces $1B life science commitment. Fierce Healthcare. January 14, 2020. www.fiercehealthcare.com/hospitals-health-systems/upmc-enterprises-announces-1b-life-sciences-investment-commitment .
Landi H. Intermountain Healthcare taps VC firm General Catalyst to accelerate innovation, value-based care. Fierce Healthcare. May 9, 2022. www.fiercehealthcare.com/health-tech/intermountain-healthcare-taps-vc-firm-general-catalyst-accelerate-innovation-value .
Reed T. Children’s Hospital of Pennsylvania spinoff investment pays big with Roche acquisition. Fierce Healthcare. February 27, 2019. www.fiercehealthcare.com/hospitals-health-systems/children-s-hospital-philadelphia-spinoff-investment-pays-off-big-roche .
Hanreich C, Boettner F, DeNegre S, Jungwirth-Weinberger A, Jerabek S. The impact of the COVID-19 associated shutdown on orthopedic patient care. Arch Orthop Trauma Surg. 2022; May 19:1-8.
Herzlinger RE, Schneller E. Ten year sunset rule for healthcare regulation is a nonstarter and discouragement to post-COVID-19 Investment. Journal of Health Care Finance. Spring 2021. www.hbs.edu/faculty/Pages/item.aspx?num=60063 .
Patel N. 90% of startups fail: here’s what you need to know about the 10%. Forbes. January 16, 2015. www.forbes.com/sites/neilpatel/2015/01/16/90-of-startups-will-fail-heres-what-you-need-to-know-about-the-10/ .
Eisenmann T. Why start-ups fail. Harvard Business Review. May-June, 2021.
Appelbaum E, Batt R. Private equity in healthcare: profits before patients and workers. December 14, 2021. cepr.net/private-equity-in-healthcare-profits-before-patients-and-workers/ .
Parramore L. ER doctor: private equity is killing American healthcare. Institute for New Economic Thinking. September 23, 2021. www.ineteconomics.org/perspectives/blog/er-doctor-private-equity-is-killing-american-healthcare .
Grant K. Is private equity a dangerous employer? MedPage Today. October 14, 2021. www.Medpagetoday.com/special-reports/exclusives/95022 .
Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Health Care. McGraw Hill; 2017.
Herzlinger RE. Why innovation in health care is so hard. Harvard Business Review. May 2006.