Orthopedic Practices Face Growing Challenges in COVID-19

In March 2020, the 2019 novel coronavirus forced most states to ban elective musculoskeletal surgeries to reserve personal protective equipment (PPE) for hospitals and health providers treating patients with COVID-19, the disease caused by the 2019 novel coronavirus. On March 30, 2020, the American Alliance of Orthopaedic Executives (AAOE) surveyed its members to understand the potential impact of these elective surgery bans on orthopedic practices. With a sample size of 100 practices responding, the sample represents approximately 10% of AAOE's member practices.

Elective surgeries include surgical cases where delaying the surgery can be done without causing significant harm to the patient or the eventual outcome. These surgeries include total joint replacements; spinal fusions; rotator cuff, posterior cruciate ligament, and degenerative meniscal repairs; carpal tunnel surgery, etc. In most states that established a ban on elective surgeries, this ban also included any ambulatory surgery centers that were performing these services.

Results of the survey indicate a high degree of uncertainty for orthopedic practices across the country.  Prior to March 2020, members reported an average of 700 elective surgeries per month. By April 2020, this average had dropped to an average of 273 per month, a decrease of 61% (see Table 1). When asked how many elective surgeries would be cancelled if the public health emergency lasted for six months or longer, members indicated that this average could further fall to 70 elective surgeries per month, a 90% decrease from the pre-COVID baseline.

Given that elective surgeries make up, on average, 73% of a practice’s total volume, these results emphasize the challenges facing orthopedic practices. Using data on total revenue (which includes elective surgeries) from AAOE’s annual Benchmarking Survey of orthopedic practices, we can further explore the difficult circumstances currently faced by the orthopedic specialty.

Elective Surgery Graph

The median monthly orthopedic revenue is $441,366 according to the AAOE Benchmarking Survey (see Table 1). If this revenue is reduced to include only non-elective surgeries (i.e., total revenue minus 73% elective surgery volume), the monthly revenue is reduced to $119,169. Further, based on the results of the COVID-19 impact survey, we can estimate the amount of revenue that practices will retain if elective surgeries are reduced by 61% (i.e., a decrease in revenue from $322,197 to $119,213).  Thus, under the elective surgery ban, orthopedic practice total monthly revenue would drop from $441,366 to $238,382 (see Figure 1). With median monthly total expenses for orthopedic service reported at $256,247, all other things equal at the outset of the public health emergency, orthopedic practices were earning just under what it takes to cover expenses.



Median Monthly Amount

Average Size of Physician Group


13 Physicians

Orthopedic Practice Revenue

Benchmarking data


Non-Elective Surgery Revenue

Orthopedic Revenue – (Orthopedic Revenue x 73%)


Elective Surgery Revenue

Orthopedic Revenue – Non-Elective Surgery Revenue


Elective Surgery Revenue – Adjustment for COVID-19 ban

Elective Surgery Revenue – (Elective Surgery Revenue x 63%)


Monthly Orthopedic Revenue during Elective Surgery Ban

Non-Elective Surgery Revenue + Elective Surgery Adjusted for COVID-19


Median Monthly Orthopedic Expenses

Benchmarking data


Table 1

To preserve the practice and prepare it to weather the financial storm, orthopedic practices are cutting expenses. With an average staffing level of 179 employees prior to COVID-19, practices are now reporting an average staffing level of 139 staff, a decrease of 22%. Keep in mind, these numbers were collected in the end of March and have likely increased since as the scale and scope of the virus and its economic fallout continues to evolve.

There have been other implications for orthopedic practices besides the financial. One orthopedic practice was evicted from their hospital leased office space with seven days’ notice to make room for COVID-19 related treatment. Others have paused capital improvements, hiring new surgeons or other clinical staff, and adding a new service line. Still others have seen mergers fall apart as uncertainty around the economic downturn swirls.

Beginning in May 2020, many states with bans on elective surgeries are beginning to loosen the restrictions on performing elective surgeries however, it will likely be some time before numbers are back to the pre-COVID-19 levels. We may avoid the direst predictions of our members when asked to project six months into the future, but it is clear that normal operations and revenue flows will not resume quickly.