At the vanguard of musculoskeletal care: (third from left) Stephen Katz, MD, director, National Institute of Arthritis and Musculoskeletal and Skin Diseases with (left to right) Kimberly Templeton, MD, president, USBJI; Edward Puzas, PhD, past-president; and Toby King, executive director.
Courtesy of USBJI


Published 4/1/2012

The Value in Musculoskeletal Care

USBJI issues Summary and Recommendations

The concept of “value” often tops any discussion of healthcare reform. In October 2011, 125 representatives of the musculoskeletal care community gathered in Washington, D.C., to examine the value of musculoskeletal care from multiple viewpoints. The meeting, staged by the United States Bone and Joint Initiative (USBJI), was a summit of stakeholders, and patients, providers, payers, government, and industry and professional organizations were all represented.

Kimberly Templeton, MD, president of the USBJI, told those assembled that the concept of the summit arose during the strategic planning that occurred during the transition from the U.S. Bone and Joint Decade to the U.S. Bone and Joint Initiative.

“One of the goals from that discussion was to have more frequent meetings of the leadership of the various participating organizations to discuss areas of common interest so that we can move forward the agendas in research, advocacy, and education,” she said.

In addition to providing an opportunity for discussion and interaction, a clear goal of the summit was to develop a consensus statement on value that would serve as an action framework for future activities, including advocacy. Being able to define and promote value is a crucial step in ensuring appropriate outcomes, as well as adequate funding for research and care. As individuals are asked to bear a greater share of costs under healthcare reform, being able to show the value of care will become even more critical.

But value can be an elusive quality to pin down. In his opening remarks, summit co-chair David Pisetsky, MD, PhD, said, “Value is clearly something different from either cost-effectiveness or quality. We often hear the maxim, ‘if something is worth doing, it’s worth doing well.’ But with regard to value, we need to ask, ‘If something can be done well, is it worth doing?’ That’s really the difference. We usually think of output in terms of outcomes, but in the case of value, we need different parameters.”

Presentations made throughout the 2-day summit covered a wide range of topics and viewpoints, ranging from the patient’s perspective on value to the components of value as identified by the Centers for Medicare & Medicaid Services. Following the presentations, summit participants met in interdisciplinary work groups to discuss four topics central to the development of the consensus statement: definition of value; measurement of value; advocacy issues; and the role of professional organizations.

Statements addressing each of the four areas were drafted, with further refinement of the drafts to take place following the conclusion of the summit. This article includes essential excerpts of the summaries and recommendations; the complete statement is available at

Defining value
The definition of the value of musculoskeletal care agreed upon following the summit was concise: “[The] value in musculoskeletal care is a measure of the outcome of all health care services that are delivered to maximize a person’s function and participation in society while minimizing impairments, pain, and other symptoms. The determination of value therefore must consider the balance of desirable and accurately measurable patient-centered outcomes against the risk/benefit ratio and cost of care over the patient’s entire life span.”

Measuring value
The recommendations regarding the measurement of value necessarily required a degree of qualification. The value in health care can be evaluated in terms of quality patient outcomes achieved per dollar expended over the full cycle of care, including interventions from all providers.

In this assessment, self-reported, quality, patient-centered outcomes that directly address the needs and goals of patients are important elements in determining value. Thus, to promote better outcomes for patients, cost-effectiveness models should incorporate measures of quality and patient-centered outcomes and not simply focus on process measures and reducing the cost of providing health care.

To assess quality and value of musculoskeletal care, patient-centered measurement instruments are required. These measures must include well-defined indices of musculoskeletal function as well as overall health status. Furthermore, these measures must be well validated and readily performed in the clinical setting.

To provide the most incisive information for determining health status, chosen instruments should have features such as standardized communication to enable sharing across all providers and disciplines. Importantly, utilization of these instruments in routine care settings should be fast and efficient, without disrupting the healthcare interaction between patient and provider.

The role of advocacy
Musculoskeletal community stakeholders must take a very active role in educating the public, health policy makers, research institutions, and regulatory bodies at the local, state, and national levels. Key messages on value must be clear and decisive. They must be solidly based on quality patient outcomes data, as well as on accurate estimates of costs and quality.

Organizations within the muscu-loskeletal community should establish an integrated information system and research networks to provide up-to-date data on outcomes to improve patient care and educate providers.

The academic and research communities, along with other stakeholders, should work to correct the current imbalance between the extent of funding for research directed to the musculoskeletal diseases and the large societal burden of these conditions. For example, in fiscal year 2011, the National Institute of Arthritis and Musculoskeletal and Skin Diseases received just $539 million in federal funding, but the annual direct and indirect costs for bone and joint health in the United States are $849 billion.

The USBJI should encourage the Centers for Disease Control and Prevention to increase its focus on monitoring the burden of musculoskeletal disease and on developing evidence-based prevention programs, working with the musculoskeletal community.

Research should address programs of integrated care and should focus on patient outcomes that maximize patient function, longevity, and societal role; address healthcare disparities; assess the impact of musculoskeletal conditions on other chronic health conditions; and involve the prospective study of outcome and value measurements.

Training programs for all healthcare providers should improve the knowledge, skills and attitudes of all professionals in the diagnosis and management of musculoskeletal conditions.

Academic institutions and other healthcare organizations should develop a vertically oriented model that encourages a collaborative and interdisciplinary approach to patient care.

New models for health care should be flexible and adaptable as demographics shift, especially for underserved populations and groups susceptible to certain musculoskeletal conditions and their attendant comorbidities.

The workforce for musculoskeletal care should expand across all healthcare disciplines to meet the demands of the population.

Professional organizations
Musculoskeletal specialty professional organizations and patient-centered voluntary health organizations play critical roles in efforts to increase the value of musculoskeletal care. These groups should be encouraged to incorporate the value discussion in their advocacy efforts to government leaders at all levels.

Organizations should work collaboratively to increase knowledge about musculoskeletal conditions among healthcare providers, patients, and families to provide the highest value of care to individuals with—or at risk for—musculoskeletal conditions. In conjunction with the USBJI, organizations should identify existing patient-centered instruments and develop novel ones to measure quality and value and encourage their routine use. Furthermore, these organizations should encourage prospective research to monitor, analyze, and propose enhancements to those instruments.

Organizations, either through the USBJI or independently, should develop multi-disciplinary, longitudinal care continuum models for musculoskeletal diseases and conditions.

These organizations should engage “medical home” and other providers in the development and dissemination of optimal musculoskeletal care models, taking into consideration the impact of musculoskeletal disease on other chronic health conditions; inform their members of evolving care models and prepare them to be leaders of innovation in their communities; promote prevention and value strategies across disciplines; and foster a culture of professional collaboration across providers focused on patient-centered functional outcomes.

Many patients have musculoskeletal conditions that are not supported by patient advocacy groups. Healthcare providers may lack knowledge about the diagnosis and management of these conditions, which can impede timely diagnosis and implementation of care. The USBJI and its network of more than 100 patient and healthcare professional organizations should provide visibility for these patients.

Additional information

USBJI summit addresses value of musculoskeletal care

The Value in Musculoskeletal Care (2011)