“In My Experience…Transforming the Delivery of Musculoskeletal Care”

The challenges facing our healthcare system are more daunting than ever, and I have focused my career on how we can address these issues in ways that better serve patients. Simply stated, we must transform care to deliver great outcomes at lower cost.

As a preface I know orthopedic surgeons want to do their best for their patients. They want them to have amazing outcomes. But we are part of a fractured system which does not put the patient at the center. We are pushed to see more patients in less time. Communications between clinicians caring for the same patient are, at best, fragmented, if they occur at all. Education and training of orthopedic surgeons in non-surgical care is limited. We overutilize advanced imaging which may lead to inappropriate surgeries.

This culture is driven by our flawed fee-for-service payment model. Every healthcare system relies on procedures, advanced imaging and elective surgeries to generate a positive financial margin. After all, our hospitals were full of very sick patients during the pandemic, yet hospitals were hemorrhaging funds. The margin from surgical service lines subsidizes non-remunerative service lines (e.g., pediatrics, infectious diseases). Hence surgical volume is a key performance metric, and surgeons are pushed to operate more.

Transforming the delivery of musculoskeletal care to be more patient-centered and value driven has been my passion for many years. After experiencing the challenges of transforming care in a very traditional system, I left the comfort and security of academia to co-found a company called Vori Health in 2021. We are a digital first nationwide musculoskeletal medical practice with non-surgeon physicians (PM&R), nurse practitioners, physical therapists, health coaches and registered dietitians. Our contracts are built on value-based payment models: a bundled payment for one year of services or a population health type per member payment. These models give us the flexibility to provide health coaching and dietitian services to our patients—services not typically covered by insurers.

This biopsychosocial model is the key to improving health. Better sleep, an anti-inflammatory diet, less stress—hey, those all sound good to me! But we know that behavior change is difficult for each of us, and that is why the coaching and nutrition aspect of our model is so important. This model also supports patient engagement—if physical therapy will help the patient, but the patient will not do their exercises, we have failed. Our focus is initial non-surgical care, and to escalate the patient to the surgeon as needed. I often summarized our approach as not anti-surgery, just anti-inappropriate surgery.

The work is hard and exciting, all at the same time. I have had to learn about health plan contracting and population management. The speed of change in a start-up is wonderful, like light-years ahead of academia. I don’t have to go through 8 committees for sequential approvals to innovate. For example, in the span of about one month, we piloted and then adopted a new initial evaluation model in which both the physician and physical therapist evaluate the patient together during the same (first) digital visit. The physician renders the medical diagnosis and the physical therapist the functional diagnosis, and both are aligned on the treatment plan moving forward—with the patient experiencing this level of communication and collaboration. Patients reported overwhelmingly positive feedback. We published our survey results with my favorite finding being that 92% of the patients say that the visit format helped them “better understand their medical condition and how to start treatment.” I found that so powerful as we know that low health literacy is so common.

Often, I am asked what I think is the ideal healthcare system. My nirvana system would be one in which health promotion efforts are centered in communities, and sick care in clinician offices and hospitals. We need healthy eating and promotion of movement and physical activity to be community-based efforts—and this is particularly critical for our underserved communities. Since 2010 I have had the honor to chair Movement is Life, a non-profit focused on eliminating musculoskeletal health disparities, and we know that community-based programs work! So, in my re-imagined system we would make our communities safe for outdoor physical activity, sponsor effective programs to promote movement, and eliminate food deserts in which neighborhoods have limited access to fresh fruit and vegetables at reasonable prices. Of course, this is aspirational, but we must start with a vision. And I would like to invite all to join our Movement is Life Annual Summit on Friday, November 14^th in Washington, D.C. Our program is always fantastic!

Returning to my nirvana healthcare system, sick care would move seamlessly between digital to in-person care. Some care must be delivered in-person, particularly urgent and emergent care, but so much more can be delivered digitally. While moving from digital to in-person care should be seamless, it can be challenging! At Vori Health we have partnerships with national physical therapy clinic chains to support referring our digital patients who we determine would benefit from a few hands-on physical therapy sessions. Such referrals are not common. In-person physical therapy is not typically needed, but it is sometimes appropriate. What has surprised me is how infrequently our patients follow through with this in-person referral. The feedback is almost always related to the convenience of digital physical therapy—patients do not consider non-urgent in-person care to be convenient as compared to digital care. So, we have to take into account the patient experience as we look for system solutions!

In closing, I am optimistic that orthopaedic surgeons, who have always been leaders in the musculoskeletal space, will see the benefit of a more holistic digital care model. The surgeons will always, in my mind, remain at the top of the pyramid. But most surgeons currently see a lot of patients who could receive great care from musculoskeletal non-surgeon physicians, as in our model. When we refer our patients to surgeons, they are almost always surgical candidates and ready for surgery, supporting efficiency for surgeons! We must all work together to improve our system, our patients are depending on us.