The MSK Roundtable, with Chris Hamilton, Heidi Ojha, and Mark Testa

This roundtable discussion provides an in-depth analysis of the Musculoskeletal (MSK) crisis in the U.S. healthcare system, focusing on its massive financial burden and the systemic failures that lead to unnecessary surgeries and poor patient outcomes. The panelists—a benefits consultant, an upstream orthopedic diagnosis expert, and a regenerative medicine specialist—collectively frame MSK as a "death by a thousand cuts" problem for employers, noting that it accounts for an estimated 27% of the $4.5 trillion U.S. healthcare spend, making it a trillion-dollar category. A key theme is the misaligned incentives within the traditional fee-for-service model, where surgeons are incentivized to "cut" and patients, desperate for immediate relief from severe pain (often rated 8 out of 10), are quick to accept surgery as the primary intervention, bypassing conservative care.

The conversation centers on the critical need for a "stepped care approach" and the implementation of guardrails to prevent patients from skipping directly to expensive, often ineffective, surgical procedures. A major point of failure identified is the lack of standardized diagnosis, particularly the over-reliance on imaging (MRI, X-ray). Research suggests that only 5% of elective orthopedic cases require imaging, yet 60% to 80% currently receive it. This over-imaging leads to confirmation bias, where findings like "bone on bone" degeneration—which may be asymptomatic—triple the risk of a patient pursuing surgery for back pain. Furthermore, the discussion highlights the underappreciated role of biopsychosocial factors, noting that anxiety and depression are significant predictors of costly downstream orthopedic claims, suggesting that holistic treatment addressing both physical and mental health is crucial.

The panelists advocate for self-funded employers to adopt integrated solutions that centralize care coordination and leverage alternative models like Direct Primary Care (DPC) and nurse navigation. DPC physicians, whose incentives are aligned with keeping people healthy, are seen as better gatekeepers than traditional fee-for-service providers owned by hospital networks. Solutions like Aware Health (upstream diagnosis/virtual care) and Regenexx (regenerative medicine, positioned as the "last stop before surgery") demonstrate significant success in surgery avoidance. One case study showed 95% of elective cases referred to a regenerative medicine provider avoided surgery, and another client saw a 3x ROI by implementing upstream MSK care, estimating a potential 10% reduction in overall healthcare spend in year one. The ultimate challenge remains operationalizing these solutions, making them simple for employees to access, and convincing benefits advisors to move beyond analysis and actively implement proven, high-value programs.

Key Takeaways:

• MSK Cost Crisis: Musculoskeletal issues account for approximately 27% of the $4.5 trillion U.S. healthcare spend, representing a massive, often overlooked, financial burden for employers, especially since these mid-range claims typically fall below specific stop-loss deductibles.
• Avoidance Opportunity: Excluding traumatic injuries, experts believe 95%+ of elective MSK surgeries could be avoided through appropriate stepped care, skilled diagnosis, and conservative treatment, offering a huge opportunity for cost savings and improved outcomes.
• The Danger of Over-Imaging: Only about 5% of elective orthopedic cases are clinically indicated for imaging, yet 60-80% receive it. Seeing degeneration on an MRI (e.g., "bone on bone") can triple a patient's likelihood of pursuing surgery, even if the degeneration is not the source of the pain.
• Biopsychosocial Factors are Key: Anxiety and depression are significant comorbidities that predict the most costly downstream orthopedic claims. Effective MSK care requires an integrative approach that addresses the biological, psychological (thoughts, beliefs, anxiety), and social determinants of pain.
• Stepped Care Approach: The optimal care path starts with prevention, moves to physical therapy (PT), then potentially regenerative medicine (platelets, bone marrow concentrate), and finally, surgery only when clearly indicated (e.g., complex tears, fractures).
• DPC as a Gatekeeper: Direct Primary Care (DPC) doctors, who are not incentivized by hospital networks, are better positioned to provide unbiased diagnosis and guide patients toward conservative care, contrasting sharply with the inertia of the traditional fee-for-service system.
• The Value of Direct Access to PT: Research indicates that allowing direct access to a physical therapist before seeing a physician can reduce the cost per claim by about $2,000, promoting earlier, less invasive intervention.
• Incentivization Structure: Employers should use "carrots" (e.g., zero copay/deductible for upstream, high-value MSK solutions) rather than "sticks" (penalties) to drive members toward appropriate care pathways, while maintaining normal plan costs for less appropriate options.
• Adviser Fiduciary Responsibility: Given the high rate of unnecessary surgery (up to 85% in some regions for back surgery) and the associated risks, employers have a fiduciary responsibility to investigate their MSK spend and implement proven solutions to protect both their budgets and their employees' health.
• Need for Centralized Coordination: To overcome member confusion caused by unbundled point solutions, a central hub—such as a dedicated nurse navigation team or DPC provider—is essential to coordinate care, educate members, and ensure continuity across the care continuum.
• Performance Guarantees: When vetting vendors, employers should prioritize solutions that offer strong performance guarantees, such as high ROI guarantees or, critically, the ability to terminate the contract quickly (e.g., 30 days notice) if the solution is not delivering expected results.

Key Concepts:

• MSK (Musculoskeletal): Refers to conditions affecting the muscles, bones, joints, ligaments, and tendons.
• Stepped Care Approach: A standardized, sequential model of care that begins with the least intensive, most conservative treatments and progresses to more intensive interventions (like surgery) only if necessary.
• Biopsychosocial Model: A holistic approach to health that recognizes the interconnected roles of biological factors (anatomy, physiology), psychological factors (thoughts, emotions, beliefs), and social factors (support, environment) in health and illness, particularly chronic pain.
• Regenerative Medicine: Treatments (such as Platelet-Rich Plasma or Bone Marrow Concentrate) that use the body's own cells to heal injuries, often serving as a highly effective, conservative step before surgery.

Examples/Case Studies:

• Lakeland Auto Mall: A self-funded client that successfully implemented a DPC and nurse navigation model alongside upstream MSK solutions, seeing high engagement (14% of population in three months) and working to avoid surgery for 12 individuals in that period.
• Back Surgery Statistics: Over half of back surgeries are considered unsuccessful, with patients still seeking treatment for pain within one to three years post-operation. In some areas, up to 85% of back surgeries are deemed unnecessary.
• Regenexx Data: Data shows that 95% of elective cases coming into their program (as the "last stop before surgery") do not require subsequent surgery.