Somewhere between the moment a knee gives out and the moment a surgeon decides whether to operate, a series of decisions gets made.
Is this urgent or routine?
Imaging now or watchful waiting?
Physical therapy, an injection, a specialist visit or nothing at all?
Whoever controls those initial decisions controls the patient, the downstream revenue and, increasingly, the data that defines the episode. In orthopedics, that control is up for grabs, and surgeons are no longer the presumptive owners.
The question of who owns triage sounds operational. It is strategic. Under episode-based payment, the front door determines who carries the cost and the risk of everything that follows. And a growing field of competitors — primary care, urgent care, digital musculoskeletal platforms and now AI — is competing to be the place a patient with a bad back or a torn meniscus goes first.
Why triage became a battleground
For most of orthopedics’ history, triage was somebody else’s job. A patient saw a primary care physician, got a referral, waited weeks and eventually landed in a surgeon’s office. The surgeon owned the operation and little else.
That passive posture is now a liability. Kevin Bozic, MD, chair of surgery and perioperative care at Dell Medical School at the University of Texas at Austin, has warned that surgeons who cede the surrounding care risk making themselves optional.
“If we silo ourselves into proceduralists, we’re going to make ourselves less relevant,” he told Becker’s.
The reason is that the most valuable asset in musculoskeletal care is not the surgery. It is the longitudinal relationship with the patient, and that relationship starts at triage.
Digital physical therapy platforms and musculoskeletal point solutions are positioning themselves as the front door and the long-term manager of these conditions.
“There are a lot of others now vying for primacy in that space,” Dr. Bozic said. Whoever answers the patient’s first question sets the pathway, and often keeps the patient.
The case for the orthopedic group
The strongest argument for orthopedic groups owning triage is clinical accuracy. Musculoskeletal complaints are among the most common reasons patients seek care, and they are easy to route to the wrong place. A patient sent to the emergency department for a problem that needed an office visit, or parked in months of physical therapy for a problem that needed surgery, is a patient whose care costs more and often turns out worse. An orthopedic group that runs its own triage, through immediate care clinics, direct scheduling and advanced practice providers, can route each patient to the right setting the first time.
That is also where access and reputation now intersect.
“Patients expect to be seen quickly and often judge practices by how easy they are to engage before ever stepping into a clinic,” Daniel Goldberg, senior vice president of sales and growth at Atlanta-based United Musculoskeletal Partners, told Becker’s. He described access as “inseparable from reputation,” with long waits and scheduling friction shaping how patients perceive a practice as much as the clinical care itself. A group that owns the front door owns that first impression.
Some large systems have already operationalized this. Danville, Pa.-based Geisinger uses teleorthopedic triage and orthopedic urgent care clinics to keep musculoskeletal patients out of the emergency department while routing them quickly to specialized care, according to Becker’s reporting on the system’s Musculoskeletal Institute.
Owning triage also protects the economics. As CMS moves orthopedics toward episode-based and longitudinal payment through the Transforming Episode Accountability Model and a new Ambulatory Specialty Model that shifts Medicare risk onto individual spine and orthopedic surgeons, the entity that controls the first decision controls the cost curve of the whole episode. Ceding triage means absorbing risk on decisions made by someone else.
The case against surgeons owning it
There is a credible counterargument: Surgeons are the most expensive and most constrained node in the system, and routing every musculoskeletal complaint through them is neither scalable nor cost-effective. Most back and joint pain never needs a surgeon at all. A triage model that funnels everything toward surgical practices risks overtreatment, the exact criticism payers and policymakers level at fee-for-service orthopedics.
This is why primary care, physical therapy and digital platforms have a legitimate claim. Conservative care resolves most musculoskeletal cases, and a well-designed non-surgical front door can be faster, cheaper and more convenient. The threat to orthopedic groups is not that these competitors are worse at triage. It is that they may be good enough, and better positioned at the point of first contact.
The resolution most leaders are converging on is not surgeons personally triaging, but orthopedic organizations owning the triage system while staffing it with the right mix of advanced practice providers, physical therapists and technology, reserving surgeon time for the patients who need it.
Enter AI, the newest claimant
The most disruptive entrant is not another provider. It is software. AI is emerging as a triage layer that can sit in front of any of these players, and orthopedic leaders are racing to deploy it before someone else’s algorithm becomes the front door.
Christian Pean, MD, an orthopedic trauma surgeon at Durham, N.C.-based Duke University School of Medicine and executive director of AI and IT innovation for Duke Orthopedic Surgery, sees patient-facing AI as the next major lever for access.
“We’re starting to look at patient-facing artificial intelligence that can bridge the gaps in our digital front door,” he told Becker’s, pointing to reducing call-center abandonment and improving first contact.
His framing matters for the ownership question. In his view, AI should not replace the human touch but sort for it.
“Patients who truly need that human touch should be prioritized,” Dr. Pean said. “Those who are comfortable getting their questions answered by an AI agent don’t need to take up the time of a nurse or clinician.” Used that way, AI is not a competitor for triage. It is the tool that lets an orthopedic group own triage at scale without drowning its clinicians.
Dr. Pean was also candid about the limit: “We’re going to find that there are areas where AI has no business being implemented. Patient trust is what we’re dealing with.”
The bottom line
Owning triage is not a byproduct of being good at surgery. It is a deliberate build: immediate care and orthopedic urgent care access so patients are not defaulting to the emergency department, frictionless digital scheduling, advanced practice providers and physical therapists empowered to evaluate and route, standardized pathways so decisions are consistent rather than surgeon-by-surgeon, and increasingly an AI layer to handle first contact and sort acuity.
That takes capital and coordination that many independent groups struggle to muster alone, which is partially why some are consolidating into larger physician-led platforms. The groups best positioned are the ones already treating the front door as a strategic asset rather than a scheduling utility.
Because triage will be owned by someone. The only question is whether orthopedic groups claim it or inherit whatever pathway a payer, a primary care network, a digital platform or an AI vendor builds for them. The clinical argument favors the specialists who understand musculoskeletal disease best. The economic argument favors whoever controls the first decision under episode-based payment. Both point the same direction: Groups that want to stay central to musculoskeletal care cannot afford to let triage happen to them.
As Dr. Bozic put it, the alternative is relevance itself. The surgeons who stay relevant will be the ones who decided, early, to own the front door rather than wait behind it.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
