Emmett Bernsohn
For most of the last two decades, healthcare’s cost conversation happened between providers and payers. Patients paid a copay, insurance covered the rest, and the practice’s revenue cycle was largely an insurance-collections problem. That arrangement has been quietly dismantled by the growth of high-deductible health plans, and few specialties feel the shift as directly, or as early, as orthopedics.
The cost-sharing trend isn’t new, but it’s compounding
Employer-sponsored family premiums reached $26,993 in 2025, the third consecutive year of 6% or higher growth, and the first time in two decades that has happened.¹ Average single-coverage deductibles have climbed from $1,217 a decade ago to $1,886 today.¹ More than a third of covered workers are now enrolled in a plan with an individual deductible of $2,000 or more, a share that has grown 77% over the past ten years.²
Averaged across all outpatient and inpatient services, this shows up as a meaningful but manageable number: people with employer coverage paid $869 in total out-of-pocket cost-sharing in 2023, split between deductibles, copayments, and coinsurance.³ For a routine primary care visit or a maintenance prescription, that figure is background noise.
For an orthopedic patient scheduled for surgery, it isn’t.
Orthopedics carries a disproportionate share of the burden
A peer-reviewed analysis of commercially insured patients undergoing elective orthopedic surgery between 2014 and 2019 found mean out-of-pocket costs of $3,180 for anterior cervical discectomy and fusion, $3,166 for posterior lumbar fusion, $2,884 for total hip arthroplasty, and $2,733 for total knee arthroplasty.⁴ Those figures are three to four times the average patient’s entire annual cost-sharing total cited above, incurred in a single episode of care. The same study found that total out-of-pocket costs for these procedures grew significantly across the study period, and that patients enrolled in high-deductible health plans carried the highest episodic costs of any plan type.⁴
The pattern holds outside major joint and spine surgery, too. A separate analysis of common outpatient foot and ankle procedures found average out-of-pocket costs rose 55% over a decade, from $875 in 2010 to $1,358 in 2020.⁵ Orthopedic care is expensive enough, and scheduled far enough in advance, that many patients satisfy their annual deductible during a single episode of care rather than gradually over multiple visits.
That difference matters operationally. A primary care practice can often absorb a slow shift in patient responsibility through incremental changes to front-desk collections. An orthopedic practice is asking patients to plan for, and pay, thousands of dollars around a single procedure, often on a timeline set by pain and function rather than by the calendar year or paycheck cycle.
The old collections playbook is straining under the new math
Practices have not been standing still, but the data suggests the ground is shifting faster than workflows can adapt. Time-of-service copayment collection fell to 56% in 2022, down from 89.9% in 2019. Over the same period, the share of patient-due balances collected at time of service rose to 39% from 14.76%.⁶
Read together, those two numbers tell a specific story: practices are getting better at collecting the harder category of payment, the patient-due balance, precisely because there is more of it to collect, and it can no longer be treated as an afterthought to the copay.
Practices are responding. A May 2024 poll of 333 medical group leaders found 41% had updated their patient payment plans or options in the prior year, up from just 27% in a comparable 2021 poll.⁶ That is a meaningful acceleration, but it also means a majority of practices had not made a change, even as the underlying patient balances kept growing.
At the industry level, the pressure is now structural rather than cyclical. In the J.P. Morgan Payments survey, patient collections have become providers’ primary revenue concern, with that concern increasing 133% between 2011 and 2024, and 71% of providers report it takes more than 30 days to collect payment after a patient encounter.⁷
For a specialty practice managing surgical schedules, implant costs, and post-operative follow-up, a payment cycle measured in months rather than weeks is a real cash flow problem, not just an administrative inconvenience.
What’s actually driving the friction
It’s worth being precise about what’s changed. The infrastructure for billing patients has generally improved across healthcare: statements are more often digital, and payment portals are more common than they were five years ago. The friction isn’t primarily about delivery mechanics. It’s about what patients are being asked to do once the bill arrives.
As deductibles climb, patients increasingly ask questions about cost, request payment plans, or make decisions about the timing of care based on what they’ll owe out of pocket.⁸ That’s a rational response to a $3,000 total hip arthroplasty bill, and it means the financial conversation with an orthopedic patient now needs to happen earlier and more clearly than a single line on a post-visit statement can support.
Regulatory requirements have moved in the same direction. Under the No Surprises Act, providers and facilities must give uninsured and self-pay patients a written Good Faith Estimate of expected charges before a scheduled service, itemized by CPT/HCPCS code, with defined timing windows depending on how far in advance the service is booked.⁹ If a patient’s final bill comes in $400 or more above that estimate, they have the right to dispute it through a federal resolution process.⁹
For orthopedic practices scheduling surgery weeks or months out, with implant and facility costs that can shift the total materially, meeting that requirement accurately is no longer optional paperwork. It’s a compliance obligation directly tied to how well a practice can produce a reliable estimate before the day of service.
What this means operationally for a specialty practice
None of this is a call for more aggressive collections. It’s a case for restructuring when and how the financial conversation happens, so that it doesn’t rely entirely on a billing statement arriving weeks after the procedure.
A few practical shifts follow directly from the data above:
Move estimates earlier, and make them real. An estimate built on actual contracted rates, not chargemaster pricing, delivered at scheduling rather than at check-in, gives patients time to plan rather than react. It also supports the accuracy bar the Good Faith Estimate requirement sets for self-pay patients, and it’s simply better practice for insured patients facing high deductibles.
Offer payment plans before the balance becomes a collections problem. The trend toward more practices updating payment plan options suggests the practices moving fastest here are treating flexible payment terms as a scheduling-time conversation, not a last resort after a statement goes unanswered.⁶
Give staff the tools to have the conversation, not just the obligation to have it. Front-desk and billing staff are being asked to discuss five-figure surgical costs in the same breath as scheduling logistics. That’s a different skill and a different workload than collecting a $25 copay, and it’s reasonable for practices to invest in systems that surface accurate estimates and payment options automatically, so staff can focus on the conversation itself rather than assembling the numbers behind it.
Treat this as a patient experience issue, not only a revenue cycle issue. A patient who understands what they’ll owe and has a clear, manageable way to pay it is more likely to keep that appointment, follow through on post-operative care, and trust the practice with their next referral. A patient blindsided by a bill is dealing with a different kind of stress, on top of a joint replacement or spinal fusion recovery.
Where this fits into a broader revenue cycle strategy
Rising patient financial responsibility isn’t a problem any single tactic solves, and it isn’t a signal that billing teams are doing something wrong. It’s a structural shift in who owes what, happening faster in orthopedics than in most other specialties because the dollar amounts are larger and the timelines are more compressed.
Rising patient financial responsibility isn’t a trend orthopedic practices can control, but it is one they can prepare for. Rivia Health helps specialty practices deliver accurate upfront estimates, offer flexible payment options, and simplify the financial experience for both patients and staff.
If you’re evaluating how your patient financial workflow compares to where the industry is headed, we’d be happy to show you what’s working for orthopedic practices like yours.
Sources
¹ KFF, 2025 Employer Health Benefits Survey, Oct. 22, 2025.
⁴ JAAOS (via PMC), Patient Out-of-Pocket Cost Burden with Elective Orthopaedic Surgery.
⁵ PMC, Rising Patient Out-of-Pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgeries. ⁶ MGMA, Transparency and flexible payment options keep care within reach (MGMA Stat). ⁷ J.P. Morgan Payments, 15th Annual Trends in Healthcare Payments Report, 2025.
