Introduction and Episode Overview
[00:00:00] Stacey Richter: Episode 499. "Self-insured Employers and Other Plan Sponsors Are Paying Millions for MSK, (Musculoskeletal) Injuries That Would Have Healed Themselves." Today I am speaking with Dr. Jay Kimmel.
Hello all you and the Relentless Health Tribe trying to figure out how to do right by patients and the folks footing the bill. Welcome to it.
This is episode 499, one episode before episode 500. So come back next week for that one.
The High Cost of Musculoskeletal (MSK) Injuries
[00:00:44] Stacey Richter: Alright, so today let's talk about the “inches that are all around us”. Let's find some. Musculoskeletal spend, otherwise known as MSK spend for any given plan sponsor adds up to the tune of something like 20 or 30% of total plan spending, depending on the member demographic.
MSK rolls in at $16 PMPM I just saw, according to a report, Keith Passwater sent me a couple of weeks ago. It's the third most costly spend apparently overall. And it's easy to see why, right? On any given day odds are good. Any given plan member is gonna do something that, in hindsight, was fairly obviously a bad idea and wind up getting hurt in some low acuity way.
For example, I remember that one time I twisted my ankle on a curb getting outta my car. Given the right space, enough time and concentration, I can do the worst parking job you've ever seen in your life and manage to twist my ankle in the process, but I digress.
Here's the point.
The Problem With Unnecessary MSK Treatments
[00:01:38] Stacey Richter: MSK spend adds up really fast.
Add to that, something like 50% of spine surgeries are said to be unnecessary. The same thing goes true from injuries like twisted ankles, for example, that would have healed themselves without an ER visit. Without any intervention aside from ice, rest, and elevate.
Because it turns out that something like 80% of those twisted ankle, banged up the back types of MSK injuries are actually low acuity and a huge percentage of those will heal by themselves.
On that point, let me bring in some context here, some late breaking news. I was reading Dana Prommel's newsletter. She wrote, and I'm reading this, she wrote, "The 2026 National Healthcare Expenditure Data Reports are out, and it is another sobering reflection of our current system. Personal healthcare spending has surged by over 8%, and our healthcare spend as a share of the GDP has followed that same aggressive trajectory".
Skipping. Skipping. Okay. Then Dana writes. "The most troubling takeaway from the 2026 report is the lack of a “health dividend.” Despite this 8% increase in spending, we aren't seeing a corresponding 8% increase in longevity, wellness, or chronic disease management. People aren't getting significantly healthier. They are just getting more in “care”, and that care isn't always good. Care of the right care or care by the right type of clinician at the right time, in the right setting."
Is that not the perfect segue or what, because this is what we're talking about on the show today in regard to, again, MSK care. care that can wind up costing millions of dollars across plan members.
And it might be unnecessary because again, the twisted ankle or the pain in the lower back would have healed itself without any care, without an ER visit.
But if an ER visit was had, that patient probably is gonna wind up with a bunch of imaging. Probably is gonna wind up with a referral to a surgeon and now there's a surgery scheduled and the patient has been off work for however long all that took.
There's a lot of direct and indirect costs that may or may not add up to any given health dividend or health span, or whatever you wanna call it. Better quality of life.
Why does all this happen? How does it happen?
The White Space in MSK Care
[00:03:55] Stacey Richter: One reason is what Dr. Jay Kimmel calls the white space of MSK care. This is where a patient does a truly breathtaking job, parking the car, twist her ankle, starts to swell up, and now a decision has to be made.
Go to the ER, go to urgent care. Go home or what if it's a parent making this choice for a kid?
In the olden days, maybe that patient would've called up his or her longtime family doctor and asked what to do, and maybe if that longtime family doctor didn't know, he or she would have called up the local ortho and gotten their opinion.
Or maybe the two were sitting together in the doctor's lounge at the time, or maybe they rounded together in the hospital and, and, and there used to be lots of opportunities for spontaneous questions and answers and curbside consults.
But not today. Most of the time, really, unless you're a patient with a doctor in the family, but even for a PCP, who wants an ortho consult?
Dr. Amy Scanlan and I discussed this quite a bit in an earlier episode. There's no doctor lounges anymore. There's no coffee klatch down in radiology either. There's just a lot of cultural shifts, in other words.
But all of this, everything I have said thus far, all adds up to one big takeaway. These excess costs that don't have commensurate improved clinical outcomes, they happen because patients are on their own to triage themselves. They look at their black and blue, whatever, or they're standing there listening to their kid cry and they're deciding what to do.
And the thing is, if they choose the ER, because again, they don't have a doctor, anybody, they can just call with the right kind of clinical background, once they head into that ER and sit there for six hours and demand an MRI because now it has to be worth their time. because they sat there for six hours, but now there's a false positive and the ER docs are being conservative because of malpractice or whatever and they refer them to some sort of surgeon.
Look, everybody's doing their best with the information that they have at the time, but you can see how easy it is for a person to avoidably wind up costing a lot of money for a musculoskeletal injury that would have healed by itself.
So yeah. Let's talk about how we can get patients some help in that so-called white space. How can we get them, triage before the triage? As I managed to say, more than once in the conversation that follows. Let's get them on a good trajectory to start.
Introducing Dr. Jay Kimmel and Upswing Health
[00:06:14] Stacey Richter: Today, my guest is Dr. Jay Kimmel. Dr. Kimmel is an orthopedic surgeon and he's been in practice in Connecticut for over 35 years.
He and Dr. Steve Schutzer, co-founded Upswing Health. I talked with Dr. Steve Schutzer about Centers of Excellence in an earlier episode.
Upswing Health provides members with the opportunity to talk with an athletic trainer within 15 minutes and an orthopedic specialist within 24 hours. So instead of having a panic attack of indecision and ultimately winding up in the ER, getting coughed on in the waiting room, members have somebody helping them in this white space so they can get triaged before the triage.
I need to thank Upswing Health. I am so appreciative they donated some financial support to cover the costs of this episode.
My name Stacey Richter, and this podcast is sponsored by Aventria Health Group with an assist from Upswing Health.
Oh, and lastly, before we kick into the episode, all links to everything I just said, and will say coming up here are in the show notes as usual.
Dr. Jay Kimmel, welcome to Relentless Health Value.
[00:07:17] Jay Kimmel: Thanks, Stacey. It's a real pleasure to be here. I'm a very big fan of your podcast and looking forward to this discussion.
[00:07:23] Stacey Richter: Thank you so much.
Why don't we just start at the very beginning here. As most of our listeners know, musculoskeletal spend is a huge proportion of health plan spend.
One of the things that you have talked a lot about, if we're thinking, musculoskeletal spend, otherwise known as MSK, a lot of times the focus is put on the high acuity cases because most plan sponsors are very well aware that high cost claimants, you know, we had Dr. Eric Bricker on [EP472]. He's like, if you wanna reduce plan cost, focus on the high cost claimants, or preventing them doing something along these lines just because there's such an obvious weighting of spend in that area.
At the same time, you've talked a lot about white space. What do you mean by that?
[00:08:06] Jay Kimmel: Well, I think you are correct that MSK is always one of the top spends for self-insured employers. And yes, 80% of the problems in orthopedics are what we would call low or medium acuity problems. However …
[00:08:22] Stacey Richter: Wait, so you said 80% are low?
[00:08:24] Jay Kimmel: About 80% or so.
[00:08:26] Stacey Richter: Okay.
[00:08:26] Jay Kimmel: But the problem is if you don't address that white space and, and what we think of when we talk about the white space is that moment when someone has an orthopedic problem, could be a twisting injury or whatever it turns out to be, they usually have two questions. One, what's wrong and what do I do about it?
And if they don't have access to good information at the moment that they have a problem. Oftentimes they will go down the most expensive and very low value pathway.
So when we talk about the white space. What we're talking about is reaching out and evaluating that member or that patient at the moment that they have an injury and putting them on the right path. Because turns out, if you wind up on the wrong path, you can take some of those low and medium acuity injuries, and you can turn them into a real problem. A real cost to the employer, and of course, most importantly, a cost to the patient.
[00:09:33] Stacey Richter: So what I'm hearing you say 80% of the time an MSK injury, it's not immediately in the high acuity, high cost claimant zone.
Something happened. A patient is like, I just turned my ankle. I don't know. Do I go to the ER? What, what should happen here? And if that individual, that member is caught in that moment in time, in that white space as you call it, and it's white space for the member, like, what do I do? But it's also white space because this is before this patient hits anybody's radar, relative to spend.
If that white space isn't penetrated at some level, then that patient could, for avoidable reasons, wind up in the 20% that is high acuity and really high cost, avoidably.
[00:10:18] Jay Kimmel: Absolutely. And, and there's so many examples of that, Stacey. I mean, you, you brought up the ankle injury. We had the opportunity with the state of Connecticut employees of which there's a couple hundred thousand of them to really analyze their claims data.
One of the things that stood out to us when we analyzed that data is the millions of dollars that were spent with the diagnosis of ankle sprain.
[[00:10:43] Stacey Richter: There's a PDF, with charts and graphs about the millions of dollars that the state of Connecticut was spending on plan members with low acuity MSK injuries like ankle sprains.]]
[00:10:55] Jay Kimmel: So if you have someone who hurts their ankle, a lot of times people don't know what to do about it. Let's say you trip on a curb, or if you're playing basketball and you twist your ankle, it turns out if you can walk on your ankle and it doesn't hurt when you touch the bone, that even if you have a little fracture, it's not gonna be clinically significant.
So if you had the opportunity at the moment that you twisted your ankle to talk to someone who really knew what they were doing and can say to you, okay, that does sound bad. You do need to go to the emergency room.
But most of the time, you know what, if you finish playing the basketball game, you don't need to go to the emergency room and spend six hours sitting there and spend thousands of dollars to, to get an x-ray, which you need is to talk to someone at the moment that you have that problem, and then they can give you the advice and say, you know what, for that one, you can just ice it and rest it and elevate it and get a brace from Amazon, which we can help you with and, and you can really avoid a lot of that.
The state of Connecticut employees, they spend millions of dollars on ankle sprains, most of which is not necessary.
[00:12:05] Stacey Richter: This is a downward spiral because if a member/patient does decide I'm gonna go to the ER and they sit there for six hours, no one's gonna sit there for six hours and not want an MRI. You know what I'm saying?
Like, so now, now you're demanding care because you've just waited so long. Like you're not gonna accept it if someone's just like, oh, ice it and go home. Like that's probably not gonna be an acceptable answer, and certainly not the expectation after someone has committed and they know they're gonna be paying thousands of dollars for it, like they're gonna want all the things.
[00:12:38] Jay Kimmel: We have data from the state of Connecticut that shows how much of their MSK spend is directly related to emergency room visits. And it's also the indirect costs as you talked about. It's the time away from work. It's the time sitting in the emergency room.
It's the unnecessary imaging that occurs as a result of being in the ER. It's all of that together. That really makes going to the ER unnecessarily a real problem for plan sponsors.
[00:13:10] Stacey Richter: So I think it's pretty evident just based on, as you're describing it, there's two ways that this can go. And if someone for a low acuity thing winds up in the ER, it's going to be expensive, warranted, or not, is what I'm hearing.
[00:13:28] Jay Kimmel: Absolutely. And, and take another example. The, the other one that really has significant consequences for the patient and the payer is someone with back pain. They, they go to the emergency room and then as you said, if you're in pain and you're sitting there for hours you are gonna want to get an MRI scan.
And then when you get that MRI. You know, people over the age of 40 MRI scans of the lumbar spine have a lot of false positives. They show a lot of things that don't have any clinically significant findings. You're gonna have a much greater chance of having surgery in that situation again. Where you go on that pathway oftentimes dictates the costs and outcomes.
And the last thing you want to do is have unnecessary spine surgery. Again, getting back to your original point, Stacey, that's how you turn a low acuity problem into a high acuity problem, and that's one of the things that we really need to prevent.
And by addressing this white space where, you know, a lot of employers have hired centers of excellence companies, which are great and virtual physical therapy companies, which are great. But unless you really reach out and address the white space, get people at the moment that they have a problem, a lot of times it's, it's too late.
[00:14:44] Stacey Richter: So you mentioned a couple of different threads here, and I wanna pull them all together and ask you a very specific question. You mentioned that you're working with the state of Connecticut and you mentioned some of their findings. You said millions and millions of dollars.
And then at the same time, you were talking about how, and I'm not sure if this is anecdotal or if it's something that is proven by evidence. I mean, it's kind of intuitive that most of the time, I mean maybe you've got 99 twisted ankles for every obviously broken leg, right?
So like, how do we know for any given plan sponsor that there is this white space that's happening, which is resulting in problematic downstream spend or avoidable downstream spend?
[00:15:22] Jay Kimmel: I think a professional or folks that really have some experience in this area can be so helpful to people as long as you talk to them pretty soon after their injury. That's probably the key thing, because that's when people are floundering and as you said, they don't know what to do. So the easiest thing to do sometimes is go to the emergency room.
[00:15:43] Stacey Richter: Well, it also probably feels like the safest thing. Like many times people don't understand that overtreatment can be as dangerous as un undertreatment. So you know, especially if you're dealing with a child, it would feel like the right parental move to take the kid to the ER. Because you certainly don't want, the risks of the converse are high.
You know, like the kid running around with a broken bone. It's undetected like that sounds very bad.
[00:16:07] Jay Kimmel: Some of those may have been ones where it was such a bad ankle sprain that they had to go to the emergency room, but much of that was something that could have been avoided if they had the opportunity to talk to someone prior to going to the emergency room.
[00:16:22] Stacey Richter: You're saying leaving a member responsible to decide whether their child's or their own ankle sprain is serious enough to warrant emergency room care is probably not a great idea. It's very hard to tell you, you need a professional.
So I certainly can see, you know, any given plan sponsor, we've done seven shows on this I'm exaggerating slightly. There's at least two, on just how ER spend has become 6% of any given plan sponsors total spend, which is crazy.
[[And these two shows are the one with Al Lewis, episode 464, and the Through Line Show about growing ER spend corresponding pretty directly to a lack of access to primary care. That is episode 470.]]
And it's certainly been said that a lot of that spend has to do with, it's directly correlated with not having access to primary care, for example. So people are going to the ER for probably the most expensive primary care money can buy, but I also could certainly see, just given the prevalence of musculoskeletal, oftentimes musculoskeletal spend is 20, 30% of a plan sponsor spend in and of itself.
So it just certainly, I can see how making sure people with musculoskeletal issues, don't unnecessarily wind up in the ER, just sort of intuitively, if someone's gonna spend six hours there, even going to urgent care, they're gonna demands all of the things.
And you alluded to something earlier, anybody who's been through this probably understands it very well. Unnecessary imaging enables downstream things that may not, once you see it, you can't unsee it. It's an issue with incidentalomas. I've heard the gray hair of the spine, but then once you see something, all of a sudden the brain is, it's like why all that neuroplastic stuff has such a good evidence basis?
So you've got the ER spend, but then what happens? Because I also could see that the ER could be the starting point of probably a not great trajectory.
[00:18:22] Jay Kimmel: Well, that's what happens Stacey, and that is the problem. It starts that not so great trajectory. If you wind up getting an MRI scan of your back, you know, certainly in the over 40 age group, there's gonna be a whole bunch of false positives. Everybody's got a bulging disc or a little disc protrusion or something like that.
So Stacey, the problem is if you start with the emergency room, oftentimes that's going to dictate where you wind up, you get referred to a orthopedist, or you get referred to a neurosurgeon and you get put on a pathway that many times can lead to increased spending and occasionally unnecessary surgery.
So where you start your journey oftentimes dictates the pathway and the cost and the outcomes of that journey. So it's really important to try to prevent that particular problem.
[00:19:18] Stacey Richter: So what I'm hearing you say is if someone winds up in the ER or urgent care, there might be a referral made by that doctor, or you should go see an ortho or you should go to PT or you should go to see a neurosurgeon. I mean, if you go to PT, you're gonna get PT. If you go to an ortho surgeon, you're probably gonna, if you're gonna get anything, you're gonna wind up with orthopedic surgery. Or if you go to a neurosurgeon, chances are you're gonna wind up with neurosurgery.
So what I'm understanding is the place that you wind up and no shade on anybody, it's just also obviously speaking in generalities. The place that you wind first might be the place that you wind up last.
You know, if you think about this from a worst case scenario, what I'm understanding is someone turns their ankle they wind up going to the ER or they hurt their back doing something or other, they wind up going to the ER. Now they're gonna definitely want an MRI. Oh, something is found. So they get referred someplace else and no this kind of button just got pressed and incident is now afoot.
Lots of things are gonna wind up happening downstream, you know, and sometimes, of course they're certainly warranted. But as you hear often enough, 50% of back surgeries are unnecessary and don't actually help. So. That's where this 50% is coming from, is what I'm understanding.
[00:20:26] Jay Kimmel: That's exactly what happens. I think you described it extremely well.
[00:20:29] Stacey Richter: So we can kind of call this like a triage before a triage that if the patient winds up getting triaged in an emergency setting or an urgent care setting or whatever, like that's the second triage that should happen. The first one is even before that, like where's the first place that they're gonna go?
Did I get that right? And that's where this white space is.
[00:20:47] Jay Kimmel: Exactly, exactly.
The Role of Primary Care Physicians in MSK Care
[00:20:48] Stacey Richter: How do PCPs fit in this mix? Because if I'm just thinking about optimally what should happen optimally, what should happen is patients should call their PCP probably before they go anywhere. But that obviously, as we know, is, doesn't happen often enough.
[00:21:03] Jay Kimmel: Well, I think, it is important, and I think that we all agree that if we're gonna fix healthcare, it's really important that the PCPs are really the quarterback in that journey.
So ideally, yes, it would be great if of a patient who's injured or has an MSK problem would call their PCP, but oftentimes as a result of access and and difficulties and patients kind of self-selecting where they go, they don't reach out to talk to their PCPs. And as a result of that, they wind up going to high cost centers like emergency rooms or urgent care centers.
So ideally the patients would reach out to their PCPs. And they would help to coordinate that journey. But oftentimes that doesn't occur.
[00:21:49] Stacey Richter: This whole triage before the triage. What it almost feels like is in the olden days when everybody had, you know, a doctor's phone number that was a friend of a friend or something like that, like the family or their PCP, their family doctor, or they actually knew their orthopedic guy/gal on a more than a transactional basis. And they would pick up the phone and say, “Hi, my kid just sprained their ankle. What should I do?”
So it almost feels like there is a financial as well as a clinical, as well as a customer experience use case here to figure out how to operationalize this triage before the triage. They cross an entire plan population.
From your experience being on the receiving end of some of those phone calls, how do you see this?
[00:22:33] Jay Kimmel: Well, I think you talked about patients having access to their PCPs phone number, but what also used to happen back in the day is that PCPs used to have access to someone like me and my phone number and would often call me for a, we would call it a curbside consult, where A PCP would call someone like me, an orthopedist and say, what should I do with this patient?
And I think if we could somehow get back to that, that would be really helpful.
But as we both know, the PCPs are so busy now, and they have so little time to take care of these patients, and they have to spend their time and energy on the sickest ones that sometimes the PCPs may decide to just send the patient for physical therapy or get MRI scans.
And if it'd be great if they had access. And I think if we're gonna solve this problem, the PCPs really need to work hand in hand with specialists like orthopedist surgeons and sort of that triage before the triage, which used to go on years ago. And I think we've kinda lost that a little bit.
[00:23:42] Stacey Richter: I'm thinking back to something I talked about with Dr. Amy Scanlan a couple of years ago who said, who really attributed the demise of the doctor's lounge to a lot of these things that we're talking about. Because a lot of those curbside consults happen informally in the doctor's lounge. You know, orthopedic surgeon would wander in and get attacked by an internist or a PCP. It was just like, what do I do here?
[00:24:04] Jay Kimmel: You know, I think that's a really good point, and I guess I sort of forgot back in the day, but when I first started in practice many years ago, the primary care doctors would make rounds in the hospital. The orthopedic doctors would make rounds in the hospital and they would talk, and a lot of that has gone by the wayside with hospitalists and with orthopedists having mid-levels to make those rounds for them.
So there's less interaction, there's less familiarity and congeniality, but maybe we can, you know, bring some of that back someday.
[00:24:31] Stacey Richter: You've got this confluence of factors that more necessitate this triage before the triage. Because the more that any of these things happen, the more patients and members are sort of left to their own devices, including just the lack of primary care access.
Even the answering machines say, you know, if this is an emergency, go to the emergency room. You call any given doctor's voicemail, and I'm sure it's for malpractice reasons, but the message is clear.
So you know, you wind up with patients triaging themselves, probably suboptimally, especially when you realize the consequences of where they wind up triaging themselves is gonna have a huge impact on their downstream care.
Where this whole conversation is headed, it's kind of like, how do you get to that patient in the moment that they need help. Which is something that I think a lot of plan sponsors, self-insured, employers, just plans of any kind are thinking of.
There's a lot of eyes on trying to figure out how to get to a patient right time, right place, Matt McQuide talked about this [EP468] quite a bit relative to nurse navigators. Dr. Christine Hale was on the pod talking about this also, Dr. Eric Bricker mentioned it [EP472].
[00:25:39] Jay Kimmel: Yes, access is key. You really can't help people and you can't solve this problem of people self-selecting and going down the wrong path unless you meet them at the moment that they have the injury.
Stacey, I would love to give everybody my phone number and have them text me when they have a problem. And before we talk today, I was playing tennis and I had two of the people that were playing with me show me various parts of their body and ask for advice. And if we could somehow go back to those days or if employers could set up their plan designs so that their employees would feel comfortable doing that and getting that information immediately, then that would go a long way towards solving the problem.
[00:26:25] Stacey Richter: And that sounds like it was the impetus behind Upswing Health. It's, it's like, here's a number you can call.
[00:26:29] Jay Kimmel: That was the idea. Yes. To give everybody access to an orthopedic surgeon in their pocket. We've talked Stacey a lot about the cost and the importance of being put on the right path or the triaging before triaging.
But I think one thing that's probably the most important is just how happy people are when you help them in this matter, when you give them advice. If you can stop somebody from going to the emergency room unnecessarily or put them on the right path, they are just incredibly grateful. And, that's, you know, makes, uh, all of us in this field that are trying to change healthcare, especially hopeful.
Conclusion and Contact Information
[00:27:07] Stacey Richter: Dr. Jay Kimmel, if someone is interested in learning more about Upswing, which is the service that if somebody wants to have an orthopedic surgeon in their pocket, this is how you do it, where would you direct them?
[00:27:19] Jay Kimmel: Thank you, Stacey. I would direct them to upswinghealth.com. And we would welcome the opportunity to talk with anyone about it.
[00:27:25] Stacey Richter: Dr. Jay Kimmel, thank you so much for being on Relentless Health Value Today.
[00:27:29] Jay Kimmel: Thank you, Stacey.