Karl Marc Koenig, MD, MS, FAAOS


Published 12/20/2023
Karl Marc Koenig, MD, MS, FAAOS; Eric F. Swart, MD, FAAOS

The Digital ‘Front Door’: Is It Opening or Closing on Our Patients?

Editor’s note: This article is a companion piece to “The Evolving ‘Front Door’ for MSK Patients: Is the Physician In?” by Charles A. Bush-Joseph, MD, FAAOS, above.

As physicians, we have a social contract with the public that requires us to provide care that is in our patients’ best interests. As independent tradespeople, we must provide value for those with whom we are contracted—such as patients, insurers, large employer organizations, and the federal government. Unfortunately, these two “contracts” are not always aligned, and there is at least some daily conflict as we provide care for patients.

Karl Marc Koenig, MD, MS, FAAOS
Eric F. Swart, MD, FAAOS

The recent trend toward the use of digital health companies (DHCs) suggests that some payers aren’t convinced that the traditional model of directly referring patients with musculoskeletal complaints to orthopaedic surgeons provides maximum value. This trend is primarily driven by the conflict of interest inherent in the delivery of elective surgical interventions.

Under current payment models, surgeons are financially incentivized to perform procedures for their patients, which has led to concerns of possible excessive intervention. At the same time, there is mounting evidence that multidisciplinary care outcomes are superior for some common musculoskeletal problems (e.g., back pain, hip/knee arthritis), with coordination among physical therapists, health coaches, dieticians, and mental health professionals, as well as consultation with subspecialty surgeons. Multidisciplinary care may be provided in an integrated practice unit model, but the logistics of coordinating such teams may be more complex than many orthopaedic surgeons are capable of providing in their practices.

In this context, many payers are turning to alternative entry points for musculoskeletal patients into the healthcare system, including working with DHCs, who may be more focused on demonstrating value to payers. However, there are significant shortcomings with this approach that warrant consideration.

Specifically, a data-driven, algorithmic multidisciplinary model may work well for patients with mild, self-limited problems. However, for patients with more complex or serious musculoskeletal issues that may require surgical evaluation or intervention, a DHC may add unnecessary cost and delays to essential care.

The link between initial triage and connection to a surgical specialist is a gap that is inconsistently bridged with current DHCs, often leading to delays in or lack of surgical care. Payers contracting with DHCs need models and methods of accountability for the full spectrum of musculoskeletal healthcare to avoid “cherry picking” and the potential for generating even more non–value-added musculoskeletal care.

In the current state, DHCs may be poised to make the issues worse, as patients with severe issues who engage with DHCs will still need higher levels of care and more costly care and may experience additional delays and detrimental outcomes. Utilizing DHCs may cause the care of self-limited disease to become more expensive. Entities that control the entry point and triage of patients must also take responsibility for the outcomes of the entire population and ensure access to the full spectrum of evidence-based treatments.

From a societal perspective, the ideal system would combine the best of both worlds: efficient, outcome-driven triage and multidisciplinary care for patients with routine musculoskeletal complaints, coupled with early identification of patients with complex issues and appropriate, timely referral to surgical specialists. This system would require the development of relationships between DHCs and surgeon groups as well as a payment model that incentivizes providing maximum value at the individual patient level, such as a condition-based payment. Given Medicare’s movement toward accountable care organizations and value-based arrangements, there will be a “buyer” for entities that can provide the full spectrum of care for musculoskeletal conditions.

As orthopaedic surgeons, we must decide where we fit in this type of future. Do we want to act as “owners” of musculoskeletal medicine, leading and directing multidisciplinary teams? Or do we want to act more as proceduralists, providing technical expertise for the smaller segment of patients who fail initial nonoperative treatments? There are pros and cons to both approaches, but failing to assume ownership of musculoskeletal disease may decrease our autonomy regarding which patients we see in our clinics and the treatments that we are able to offer them.

Given the high level of training required to become an orthopaedic surgeon and our complete focus on musculoskeletal care, it is clear that orthopaedic surgeons have the expertise and skills to act as coordinators and directors of care for patients with musculoskeletal complaints, lead multidisciplinary teams, and develop pathways for transparent outcome reporting. If we shy away from this responsibility, history suggests that someone else—for example, organizations such as DHCs or other disruptive market forces—will step in to fill that role, and we may find ourselves relegated out of the major decision-making process for our patients. We suggest that orthopaedic surgeons stay heavily involved in the development of new payment models, closely monitor DHCs, and continue to engage as the leaders of musculoskeletal care for the future.

Karl M. Koenig, MD, MS, FAAOS, is an associate professor of surgery and perioperative care, division chief of orthopaedic surgery, and medical director of the Musculoskeletal Institute at Dell Medical School at the University of Texas at Austin. Dr. Koenig is also chair of the AAOS Health Care Systems Committee.

Eric F. Swart, MD, FAAOS, is an assistant professor of orthopaedic surgery for the Department of Orthopedics at Lahey Medical Center, Burlington, Mass. Dr. Swart is an Orthopaedic Trauma Association fellowship–trained traumatologist with a practice focus on limb salvage and reconstruction and infection/osteomyelitis.