Published 12/20/2023
Charles A. Bush-Joseph, MD, FAAOS

The Evolving ‘Front Door’ for MSK Patients: Is the Physician In?

Editor’s note: This article is part of the Healthcare Safety series, which highlights the work of the AAOS Committee on Healthcare Safety, whose vision is to optimize musculoskeletal health and eliminate complications.

The evolution of healthcare in 2023 was characterized by several trends, including hospital system mergers, private practice consolidations, and private equity’s inroads with expanding physician practice ownership. These ever-growing entities compete for new patient acquisition while striving to increase efficiency and lower the cost of care.

In 2020, 163 million Americans, or 60 percent of the nonelderly population, were covered by employer-sponsored insurance programs. Employers continue to look for innovative approaches to manage musculoskeletal (MSK) care, which often approaches 30 percent of total medical expenditures. The use of digital care in orthopaedic offices (e.g., telehealth, virtual physical therapy, remote patient monitoring) is becoming more common. Although these innovations have increased patient satisfaction and outcomes, they have failed to decrease the cost of care.

The Business Health Group represents 72 of the 100 largest public companies (S&P Top 100) and noted that, until recently, MSK care was the largest driver of healthcare spending. Prescription drug spending is now 21 percent of employer healthcare cost, with the majority going to specialty medications. Despite this new trend, employers are still searching for ways to decrease MSK healthcare expenses for their employees.

Private equity and market disruptors are attempting to control expenses by controlling the “front door” for patients entering the healthcare system with MSK complaints. The traditional model of patients seeking care with a primary care physician or physician extender (e.g., physician’s assistant, nurse practitioner) is being tested by digital health companies (DHCs) such as Hinge Health, Sword Health, and Kaia Health.

The role of DHCs in MSK care
MSK DHCs contract with large- and medium-sized employers to provide care options directly to employees. The DHC charges the employer a per-member annual fee, with varying service options, and the company often guarantees the employer significant cost savings over traditional models of care due to lower rates for diagnostics and surgery. Hinge Health claims contracts with more than 1,700 companies, using a therapy-based approach to avoid injections and surgeries. Kaia Health claims more than 60 million covered lives and more than 500,000 current users. Sword Health’s website states: “The best surgery is no surgery. [Sword’s algorithm] uses machine learning to identify members who are at-risk for surgery, more than 8 months before a decision has been made to operate, and helps them avoid unnecessary and costly hip, knee, and back surgeries.”

DHCs provide digital initial and follow-up MSK care to users on a 24/7 basis. These entities seek to engage patients with MSK complaints by providing online triage via digital “care assistants,” who provide management and therapeutic physical therapy. Although company websites are nonspecific as to the qualifications and experiences of the digital “care assistants,” many note the use of physical therapists to provide therapeutic protocols and feedback. Some patients receive coaching and support from a certified “health coach.”

Although physician-level care does not seem to be involved in the primary offerings of these entities, many MSK DHCs are developing relationships with preferred orthopaedic networks who form a “downstream network” to provide diagnostics or invasive care if needed. For instance, OrthoLive is an MSK DHC that is developing a similar employer-based service but claims to provide board-certified orthopaedic experts with unlimited one-on-one follow-up visits. OrthoLive has developed a national orthopaedic network providing priority imaging and in-office appointments. Many Fortune 500 companies are now providing this service to their employees with $0 out-of-pocket costs to encourage adoption. Private investment in MSK DHCs exceeded $1 billion in 2022 alone.

Criticisms and impact on care
Although DHCs cite significant cost savings and decreases in “regional variations in care,” critics of DHCs in the MSK space believe that the care model is one of “care avoidance.” Nonphysician providers initiate care plans that may delay definitive diagnosis and management when more serious or unusual conditions are present.

Hospital-based, multispecialty physician, and orthopaedic practices are combating this “front door” trend by adopting more consumer-friendly approaches to patient engagement. Orthopaedic immediate care centers and 24-hour scheduling are being implemented to capture people with more urgent needs or patients seeking greater convenience.

As the pace of change rapidly increases, orthopaedic surgeons need to understand the market disruptive forces that affect current practice patterns. If this trend continues, orthopaedists may find themselves further displaced as “downstream providers” in the MSK space.

Charles A. Bush-Joseph, MD, FAAOS, is a professor of orthopaedic surgery at Rush University Medical Center and a team physician for the Chicago White Sox and the Chicago Bulls. Dr. Bush-Joseph is a past president of the American Orthopaedic Society for Sports Medicine and a current member of the AAOS Committee on Healthcare Safety.


  1. Business Group on Health: Our Organization. Available at https://www.businessgrouphealth.org. Accessed Sept. 21, 2023.
  2. Hinge Health: For Organizations. Available at https://www.hingehealth.com/for-organizations/employers. Accessed Sept. 21, 2023.
  3. Sword Health: Homepage. Available at https://swordhealth.com. Accessed Sept. 21, 2023.
  4. Kaia Health: Homepage. Available at https://kaiahealth.com. Accessed Sept. 21, 2023.
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