For all the complexity inherent to modern healthcare, Lucas Richie, MD, manages to describe his work with disarming clarity.
As an orthopedic surgeon at Nashville, Tenn.-based Hughston Clinic Orthopaedics and chief medical officer of TailorCare, a musculoskeletal risk-based care navigation company, he puts it simply: “I’m just a bone doctor, right? I’m an MSK guy,” he said. “I get to fix things for a living.”
That mindset, direct, practical and grounded in outcomes, has not changed, but the environment it operates in has.
A system under pressure
Dr. Richie trained in a traditional fee-for-service model. What he sees today, he said, is something fundamentally shifting.
“I think the biggest thing is we’re all going to have to get there, whether you’re wanting to be on the front end of something new, or whether you’re catching up at the end,” he said. “We’re going toward a paradigm shift. The system is not broken, but there are certainly some dysfunctional episodes to it.”
Those dysfunctions show up in daily practice in the form of tighter utilization management, prior authorization denials and shrinking reimbursement.
“We see increased utilization management, difficulty getting things approved and decreased reimbursement codes,” he said. “We know that something is changing and something’s not working right, because the costs of healthcare are out of control, and there are people who just don’t have the access.”
The question, increasingly, is not whether change is coming, but how to shape it.
A rare alignment
What drew Dr. Richie to TailorCare was not a departure from surgery, but a model where incentives align, which is a rarity, he said, in healthcare.
“We’re helping the payers, we’re saving money, but first and foremost, we’re making sure the patients get better, get better,” he said. “And at the same time, the patients get happier, the payers are saving money and the providers are happy too. Usually somebody has to sacrifice. And to this point, we’re not seeing that.”
Re-centering the patient
For Dr. Richie, the foundation of care goes unchanged.
“That’s our job as the provider,” he said. “I’m still a doctor first, and my advocacy is for the patient.”
He describes himself as a conservative surgeon who expects patients to fully explore non-operative care before moving forward: “You have had to have tried and failed A, B, C and D,” he said. “And at that point we’ll talk about surgery.”
At TailorCare, that philosophy is applied earlier in the process: “We are MSK navigation, specializing in the MSK space only for value-based care,” he said.
Patients are guided by doctorate-level physical therapists and supported by predictive analytics that identify risk before conditions escalate.
The differentiator, he said, is not so much the technology itself as the timing it allows for.
The role of timing
“When they get on the phone, sometimes our intake is 30 or 45 plus minutes,” Dr. Richie said. “That’s where I’m really proud. I still say the secret sauce that we have is time, because that’s what most providers don’t have in person anymore.”
“Time translates into engagement,” he said. “The patients buy in. They finally have a better understanding of what’s going on, as well as the options.”
The outcomes reflect that engagement, with more than 90% of patients who engage reporting improvement in pain or function, he said, along with high satisfaction scores.
Changing the default path to surgery
In many cases, the decision to pursue surgery is shaped long before a patient reaches a specialist.
“If a patient’s been told by the surgeon, or even the PCP, ‘Hey, I think you need a surgery,’ they think they need that surgery because that’s all that has been informed,” Dr. Richie said.
TailorCare’s approach is to intervene earlier: “If we can get to these patients far enough upstream, then we can go over the options and say, ‘Hey, we might be able to avoid this,’ and get the buy-in from them,” he said.
That early interception can have a profound effect, as many patients pursue surgical consultations without completing appropriate conservative care.
“Sometimes an excess of 60 percent plus have not completed what we think may be adequate to try. There are procedures out there that are no more beneficial than conservative options,” he said.
For Dr. Richie, the decision remains personal.
“If it’s my 85-year-old granddad and we have the option of appropriate therapy or spinal fusion, I’m a surgeon first,” he said. “If the patient doesn’t need it, we’re not doing it.”
A different kind of efficiency
For the surgeons, the benefits of using a navigation model extend beyond outcomes and workflow, he said.
“What orthopedic surgeons do well, that nobody else can, is we can operate,” Dr. Richie said.
Navigation models help ensure surgeons are matched with the patients who truly need that skill set.
“We can help surgeons focus on the patients who truly need their skills, and take the ones who may not need their services or expertise off their plate so they can run more efficiently,” he said.
That efficiency, he added, also depends on trust at the primary care level.
“If the PCP says, ‘Hey, this is my go-to,’ it’s a very trustworthy introduction,” he said.
Rethinking value
Skepticism around value-based care persists, and in many cases, Dr. Richie said, it is warranted.
Previous efforts to control costs, he explained, have often focused on interventions that come too late in the care journey, after patients have already been guided toward a specific outcome.
“My critique of the previous iterations of cost saving is that they’re downstream,” he said. “Whereas what we’re doing is working on the patient preconditioning.”
By the time many traditional models intervene, patients may already expect surgery, creating friction when care plans are redirected and eroding trust between patients, providers and payers.
Engaging patients earlier, before those expectations are set, Dr. Richie said, allows for more informed decision-making and stronger alignment across all stakeholders.
Why it matters
For Dr. Richie, the work is not abstract. After his daughter was born with a life-threatening congenital heart condition, his family experienced both the best and worst parts of the healthcare system — lifesaving care alongside overwhelming financial and administrative complexity.
The experience reshaped how he conceives of his role.
Today, his work is not only about fixing what is broken, but helping patients navigate the system before they reach that point.
“I’m still a doctor, I’m still a surgeon,” he said. “I believe in it.”
But increasingly, the work begins earlier, long before the operating room, with a different kind of question.
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