U.S. health care spending exceeds $4 trillion. Operating within the complex health care system are models tasked with reducing cost and maintaining or improving quality and outcomes.
One model is positioning of primary care physicians as gatekeepers to an of specialists. This concept began at a time when patients routinely sought care for all medical problems from one physician trained in general patient care. Choosing care independent of an initial assessment from a PCP is considered expensive and inefficient. Insurance companies place a premium on patient choice options, with least expensive care often offered by a restricted panel of PCPs who are gatekeepers for the overall health care system.
Gatekeeper models have been shown to reduce costs and are a major focus of government and private sector efforts to control anticipated expenses. However, there is little evidence this model provides the best quality and outcomes and, therefore, its overall value beyond potentially reducing cost is speculation. It may not provide the best setting to improve patient experience and satisfaction.
The impact of the gatekeeper model on musculoskeletal care is controversial. Although musculoskeletal conditions comprise one-third of all the ICD-10 codes, less than one-third of the training and continued education of PCPs is dedicated to this area of expertise. Patients often bypass their PCP to go directly to a physician who specializes in musculoskeletal care, urgent care center or ED. According to Gaieski and colleagues, one-third or more of patients seen at these facilities believe their PCP is not capable of managing musculoskeletal problems. The issues may be even more pronounced for children and adolescents. In a study by Hsu and colleagues, up to 50% of patients sent to a pediatric orthopedic specialty clinic could have been cared for by the PCP.
Integrated vertical model
A better model for delivering high-quality and timely musculoskeletal care to a population of patients is an integrated vertical model in which initial evaluations are performed by nonsurgical providers with expertise in musculoskeletal care. While musculoskeletal symptoms can be present with many medical issues, most acute and subacute problems are readily recognized by patients as problems related to the musculoskeletal system. The PCP should be involved in the overall patient care as a coordinator of care, provided with the opinions and treatment offered by the musculoskeletal care providers, but should not be a gatekeeper where the implied incentive is to reduce cost by limiting subspecialty care referrals.
An organized, collaborative approach between PCPs and specialists improves the delivery of care for patients and reduces overall cost. The frontline provider should have added education and experience in the treatment of these problems. As the model matures, technology and treatments often rendered by orthopedic surgeons, such as ultrasound-guided injections, orthobiologics, sequential fracture care, including casting, and advanced imaging should be delegated to the nonoperative specialists so surgeons can focus on surgical and perioperative care. Office-based practices of dedicated PCPs improve patient access to care and professional satisfaction of providers.
Several private practice single-specialty orthopedic groups have developed the model with great success. Payers and patients are recognizing the difference. Some progressive institutions and multispecialty practices are also in various stages of development of this model. The challenge in larger enterprises is the silos created by various service lines to protect their patient care business.
Leadership of orthopedic and musculoskeletal care should provide the vision of a truly integrated model, framework for vertical integration and incentives focused on patient and population care. The traditional PCP gatekeeper model may provide the perception of reduced costs, but there is little evidence it provides improved patient care and experience.
As we focus on advanced concepts to provide value, we should allow patients to recognize their musculoskeletal problems and provide access without barriers to an integrated vertical system that begins with providers with expertise in musculoskeletal care and ends with surgical subspecialists. This provides an innovative approach aligned with the goals of patients, physicians, payers and government.
- Gaieski DF, et al. Clin Orthop Relat Res. 2008;doi:10.1007/s11999-008-0277-5.
- Hsu EY, et al. J Pediatr Orthop. 2012;doi:10.1097/BPO.0b013e31826994a4.
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- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: firstname.lastname@example.org.