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.
All right, 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.
For a full transcript of this episode, click here.
Here's the point. 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."
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 'care.' And that 'care' isn't always good care, or 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?
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, twists 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?
Amy Scanlan, MD, and I discussed this quite a bit in an earlier episode (EP402). 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 are 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.
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 Steve Schutzer, MD, co-founded Upswing Health. I talked with Dr. Steve Schutzer about Centers of Excellence in an earlier episode (EP294).
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.
This podcast is sponsored by Aventria Health Group with an assist from Upswing Health.
Also mentioned in this episode are Upswing Health; Keith Passwater; Dana Prommel; Amy Scanlan, MD; Steve Schutzer, MD; Eric Bricker, MD; Al Lewis; Nikki King, DHA; Matt McQuide; Christine Hale, MD, MBA; and Chris Deacon.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at upswinghealth.com and follow Dr. Kimmel on LinkedIn.
Jay Kimmel, MD, is the president and co-founder of Upswing Health, the country's first virtual orthopedic clinic. He founded Upswing with Steve Schutzer, MD, to rapidly assess, triage, and manage orthopedic conditions in a cost-effective, high-value manner, helping patients avoid unnecessary imaging, procedures, and delays in care.
Dr. Kimmel had a long and distinguished career as a practicing orthopedic surgeon with Advanced Orthopedics New England. He earned his undergraduate degree from Cornell University and his medical degree from the University of Rochester. He completed his orthopedic residency at Columbia Presbyterian Medical Center, where he trained with leaders in shoulder surgery, followed by a sports medicine fellowship at Temple University Center for Sports Medicine, where he participated in the care of Division I collegiate athletes.
He is board-certified in orthopedic surgery and is a Fellow of the American Academy of Orthopedic Surgeons. Dr. Kimmel specializes in sports medicine with an emphasis on shoulder and knee injuries and holds a subspecialty certificate in orthopedic sports medicine from the American Board of Orthopedic Surgery. He is also a member of the American Orthopedic Society for Sports Medicine.
Dr. Kimmel co-founded the Connecticut Sports Medicine Institute at Saint Francis Hospital, a multidisciplinary center dedicated to providing high-quality care for athletes at all levels, and served as its co-director for many years.
He has a strong commitment to education and served for over 20 years as an assistant clinical professor in both family medicine and orthopedics at the University of Connecticut. He has also served as a team physician at the professional, collegiate, and high school levels.
07:49 EP472 with Eric Bricker, MD, on high-cost claimants.
08:01 What is the "white space" in MSK spend?
10:43 Statistics on Connecticut's spending on plan members with low-acuity MSK injuries.
13:30 How back pain also easily transitions from a low-acuity issue to a high-acuity problem.
15:11 How plan sponsors can detect their white space downstream spend.
17:02 EP470 with Nikki King, DHA.
18:15 Why where patients start their journey often dictates where they wind up and how costly that medical pathway is.
20:48 Where PCPs fit into this MSK spend issue.
25:26 EP468 with Matt McQuide.
25:34 EP471 with Christine Hale, MD, MBA.
25:39 Why access is key.
Recent past interviews:
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Mark Noel, Gary Campbell (Take Two: EP341), Zack Kanter, Mark Newman, Stacey Richter (INBW45), Stacey Richter (INBW44), Marilyn Bartlett (Encore! EP450), Dr Mick Connors