Large orthopaedic practices offer many advantages compared to smaller groups, including more negotiating power and the ability to afford more staff members and equipment.


Published 10/1/2009
Jennie McKee

Orthopaedic groups find strength in numbers

Large practices have size on their side, but also face challenges

Solo and small group orthopaedic practices have their benefits. They can provide more autonomy than larger groups, and politics and bureaucracy may be less of an issue.

But many orthopaedists, such as Frank A. Pettrone, MD, feel that the advantages of large group practices far outweigh those available in smaller practices. One of 35 partners at Commonwealth Orthopaedics, an orthopaedic practice in northern Virginia, Dr. Pettrone says that pooling resources in bigger practices makes sense.

“The advantages of being in a large group are very strong,” he says. “I think it’s the inevitable direction for orthopaedists in the future.”

Many other orthopaedists share Dr. Pettrone’s viewpoint, including Arnold K. Cohn, MD, and Craig R. Mahoney, MD. Dr. Cohn is one of 70 orthopaedists at the Illinois Bone and Joint Institute, an orthopaedic group with eight divisions in Chicago and its surrounding suburbs. Dr. Mahoney’s practice, the Iowa Orthopaedic Center in Des Moines, Iowa, has 16 orthopaedic surgeons.

Working with partners
Having many colleagues makes consultations easy and helpful.

“If you’re seeing patients and one of your associates is working right around the corner, it’s very easy to ask for radiographic review or a second opinion,” says Dr. Pettrone. “It’s very beneficial to share surgical experiences.”

Dr. Cohn also enjoys being part of a network of orthopaedic surgeons with various specialties.

“Our organization can cover any musculoskeletal issue,” says Dr. Cohn. “My office has five orthopaedic surgeons and a rheumatologist, but we don’t have a hand specialist. When a patient with a complicated hand condition or injury comes in, I can pick up the phone and one of my colleagues will see the patient within 24 hours.”

Having many partners who can provide emergency call coverage is a major plus.

“I’m on call approximately every twelfth day,” says Dr. Mahoney. “Our call is busier because we’re a bigger group, but the frequency of call is less because call is rotated among so many orthopaedic surgeons.”

Dr. Pettrone agrees.

“We pool emergency call as well as rounds, which frees us up to see more patients,” he says. “If you have good relationships with your peers, they can cover rounds and make it easier for you to be away from the office. In a small group, it can be hard to find people to cover for you.”

Enjoying the economies of scale
Larger groups are able to afford staff and equipment that some smaller groups can’t—and they often have a lot more negotiating power. Commonwealth Orthopaedics, for example, employs more than 10 physician assistants (PAs).

“They are very helpful,” he says. “Our PAs have their own clinic hours for seeing patients. They refer patients who may need surgery to the orthopaedic surgeons, provide another skilled hand in the operating room, and can make rounds.”

The practice, like many large orthopaedic groups, also has a budget for marketing campaigns.

“Our marketing efforts have given us brand recognition,” says Dr. Pettrone. “Patients, schools, athletic teams, employers, and insurance companies in our area recognize that we provide a consistently high quality of care.”

Large orthopaedic practices often have many different types of physicians on staff. For example, the Iowa Orthopaedic Center includes podiatrists, hand and upper extremity surgeons, and a physician who specializes in physical medicine and rehabilitation.

The Illinois Bone and Joint Center has a total of 763 employees, including a corporate office with 26 employees and in-house legal counsel.

“A physician-owned company does our billing and provides medical reimbursement and information technology services to our organization,” Dr. Cohn says. “We have 14 physical therapy locations, seven magnetic resonance imaging locations, and two affiliated surgery centers.”

Although his organization hasn’t yet implemented an electronic medical records system, it does have a digital radiograph system.

“All of our films are stored digitally, and we’re working on making all the radiographs in the system available to every physician in our organization,” he says.

Such a large group obviously has a big advantage in negotiating with insurance carriers for reimbursement.

“It’s very important for the carriers to have us on their panel,” says Dr. Cohn. “We also have advantages in negotiating contracts and malpractice insurance rates, as well as in buying supplies.

“We’ve been able to hire really good managers,” he continues. “Our executive staff members serve as administrators and provide tremendous leadership.”

Keeping the lines of communication open
Because the practices are so large, the partners and staff members must make an effort to maintain good communication.

“Everyone needs to know about decisions that have been made and directions or policies that are being advanced,” notes Dr. Pettrone.

“We can attend monthly board meetings to stay updated,” he continues, “and we can also check our intranet for the minutes from board meetings and executive committee meetings.”

Dr. Mahoney’s group has board and executive committee meetings, as well as monthly quality assurance meetings.

“We also stay in touch by interacting at the office while we’re discussing cases,” says Dr. Mahoney.

‘A blessing and a curse’
Because his organization is extremely large, notes Dr. Cohn, individual orthopaedists aren’t able to control every aspect of its operations.

“There’s one central human resources department, and the policies are uniform throughout the corporation,” he says. “Although there’s less local rule on everyday issues, each group is autonomous when it comes to designing and building its space, as well as in making some hiring decisions. Each office also decides how to divide physician compensation.”

“Physician compensation agreements require negotiation in any size group,” notes Dr. Mahoney. “In a large group, it’s important to figure out a way to reimburse everyone equitably.”

According to Dr. Pettrone, having less autonomy as part of a large group practice is “a blessing and a curse.”

“Because you’re not controlling all aspects of the practice, you have to create an administrative management structure that you trust to run the group successfully,” he says. “It’s expensive, but you need good staff members.”

Dr. Cohn cautions that “geographic overlap issues” can also arise.

“We have to be careful about sticking to our own territory and not trying to expand into our colleagues’ territories,” he says.

“If one of the partners wants to expand or open another office, the entire board explores how it would affect the existing offices.”

Large practices may also face legal compliance issues that don’t apply to smaller practices, says Dr. Cohn.

Despite the challenges, he enjoys being part of a large group practice.

“My partners are great—we all like each other a lot,” says Dr. Cohn. “I can’t imagine going elsewhere.”

For another perspective on large practices, see “A roadmap to the 21st century

Jennie McKee is a staff writer for AAOS Now. She can be reached at