Musculoskeletal care is under growing pressures, from rising demand and flat reimbursement to care delays and payer denials.
Below, six orthopedic leaders share what they wish payers better understood about the real drivers of musculoskeletal outcomes, cost and patient experience.
Question: What do you wish payers understood today about musculoskeletal care?
Editor’s note: These responses have been lightly edited for clarity and length.
Brian Cole, MD. Sports Medicine Orthopedic Surgeon, Acting Chair and Managing Partner in Department of Orthopaedics at Midwest Orthopaedics at RUSH (Chicago): Musculoskeletal care is often complex and resource intensive. Placing a premium on responsible evidence-based resource utilization is critical. However, placing incremental value on relevant patient-reported outcomes, the absence of complications and reoperations and overall patient satisfaction by the payer would further the narrative that pricing and professional compensation is more than the exact cost of the care delivered. I would welcome a broadening of the current narrative between payers and providers.
Frank Kelly, MD. Retired Orthopedic Surgeon (Macon, Ga.): Although non-operative orthopedic care is almost always our initial recommendation for most conditions, there are occasional times in which early operative intervention not only leads to improved patient results and patient satisfaction, but is frequently more cost-effective. Examples might include an acute full-thickness tear of the rotator cuff or a torn meniscus with mechanical-type symptoms. In such instances, prolonged non-operative measures, such as extended therapy or injections, can be counterproductive and can compromise the final result.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: Payers continue to cut services. As the population ages, the demand is rising, but the supply of orthopedic providers remains constant. There will be a tipping point, and certain payers will eliminate access for their patients. This refers to procedure codes as well as evaluation and management codes, where the payers don’t want to reimburse same-day in-office images and injections.
Alexander Mameghani, MD. Head of Spine Surgery at Kantonsspital Baden AG (Switzerland): I wish payers understood that musculoskeletal care should begin at age 40 or 45, not after the first fracture. Osteoporosis is not a geriatric disease. It is a silent musculoskeletal burden that develops over decades. We should screen bone health early, prescribe strength training like medication, and invest in proactive fracture prevention during the very decades before patients become fragile. Waiting until 65 or 70 means we are intervening far too late, after the damage is already done. In other words: a lost quarter-century of prevention.
Elizabeth Matzkin, MD. Chief of the Women’s Sports Medicine Program at Brigham and Women’s Hospital and Assistant Professor of Orthopedic Surgery at Harvard Medical School (Boston): I wish that payers could understand the value of restoring a patient’s function versus just focusing on a diagnosis. Payers often focus on codes and utilization metrics rather than whether patients return to work, sport, caregiving and independence. What matters most to patients is pain reduction, mobility and function, and this should be considered when determining core quality metrics.
Jeffrey Wang, MD. Chief of Orthopedic Spine Service and Co-Director of the Spine Center at the University of Southern California (Los Angeles): I wish payers understood how individual our different patients can be, and how they are real people, with varying personalities, apprehensions and concerns. Some patients need more personal care, more time to recover, and more time in the hospital after a surgery. Unfortunately, payers look at them as a diagnosis and provide coverage for an average patient with that specific medical problem and do not account for the different patient variability and different needs.
