Orthopedic surgeons, like all specialists, need a steady flow of referrals, and adequate reimbursement for services. Health reform is making it harder to succeed. We all need to get smart about ACOs and other shared savings programs, and begin making changes in practices in order to prepare for the future. If you stand still, you could get swallowed up by the advancing tide. The goal for all of us in health care these days is to be better integrated with other parts of the system, so that we can do more with less in the future. Everyone from the White House to the CMS Center for Innovation to all of us knows that we will have to do more with less. The key to future success will be managing patients’ care, and managing an episode of care that extends beyond a surgery to encompass pre-admission and post-discharge services ... an evolution form orthopedic surgeon to musculoskeletal specialist.