Introduction: The Inflection Point in Musculoskeletal Care

Musculoskeletal (MSK) care represents one of the highest-spend and highest-variation categories in U.S. healthcare (Stewart et al. 2025; Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care; Board on Health Care Services; Institute of Medicine 2013). As payers, employers, and health systems continue shifting towards value-based care, the spotlight has focused on MSK to substantially reduce total cost of care (TCOC) while improving outcomes (Hung, Kain, et al. 2025). MSK surgeons (specialists) sit at the center of this opportunity since they influence clinical necessity, define patient care pathways, shape upstream and downstream utilization, and impact long-term patient outcomes (Koenig and Bozic 2015).

CMS’ TEAM, ACCESS, and Ambulatory Specialty Care models (Centers for Medicare & Medicaid Services, n.d.-c; n.d.-a; n.d.-b) highlight continuous movement towards specialty-driven accountability and population-level clinical governance. These models accelerate the transition away from fee-for-service high-volume incentives towards treatment that rewards quality, efficiency, and longitudinal patient management. As these models expand without specialist influence, care pathways designed for—rather than by—specialists risk eroding MSK surgeon influence on patient care.

The purpose of this commentary is to explain why Specialist-Led Care is a sustainable path for a truly value-based model that preserves specialist autonomy, and to outline the structural enablers and framework needed for specialists to maintain a strong leadership role and become true champions of value-based MSK transformation.

Musculoskeletal Care: The Largest Untapped Value-Based Opportunity

Musculoskeletal care is not only high-spend and high-variation but it is also structurally positioned for value-based transformation due to surgeon influence on downstream utilization (Becker’s Spine Review, n.d.; Rubin et al. 2026; Dieleman et al. 2020; Haas and Kaplan 2017; Nin et al. 2022). MSK surgical episodes are often considered to start with the specialist whose choices set the patient pathway trajectory—pathways where treatment variation remains substantial (Jenkins et al. 2015; Mafi et al. 2013). This approach limits the extent of value creation as much of the spend on MSK services across a population occurs upstream to traditional MSK specialist involvement. When viewing the MSK “episode” through the lens of a clinical journey, there are many decision points and therefore opportunities upstream of the MSK specialist’s typical interaction to influence value and clinical appropriateness. MSK specialists often lack access to sufficient clinical data, analytics, patient engagement tools, and operational systems to reliably expand their clinical influence upstream of their care. But new opportunities are emerging which incorporate the clinical expertise of MSK specialists to more substantially influence the entire patient MSK care journey. These factors are what makes MSK one of the few specialties where improved clinical governance, analytics infrastructure, and care management can meaningfully shift cost and improve clinical outcomes.

Table 1.Musculoskeletal Value-Based Opportunity
Key Driver Market Signals
High total spend Exceeds $300B annually and continues to grow faster than other specialties (Stewart et al. 2025).
High variation Wide variation in imaging, injections, conservative care sequencing, surgical decision-making, site of service, and discharge protocols (Comer et al. 2022; Sears et al. 2019).
VBC adoption opportunity Positioned to follow the value-based progress achieved in cardiology, oncology, and nephrology.
Policy tailwinds CMS specialty models and employer pressure are accelerating MSK accountability.
High impact potential Evidence-based care pathways and clinical governance can meaningfully reduce total cost of care while improving outcomes.

CMS has accelerated the shift toward specialty accountability through mandatory and strongly incentivized models that increasingly place MSK care under chronic condition or episode-based risk (Hung, Kain, et al. 2025). When specialists collaborate within multidisciplinary teams, upstream providers, and work in partnership with payers, value-based care becomes achievable while preserving the MSK surgeon’s central role in patient management. However, sustaining this model requires reimbursement structures that acknowledge the level of clinical oversight and financial stewardship necessary for high-quality care delivery. Without this alignment, the system risks reverting to the earlier—and unsustainable—“race to the bottom” challenges seen in the initial CMS bundled payment programs, which often penalized high-quality, cost-effective clinicians while rewarding lower-value, higher-waste care. Under those models, continuous demands for quality improvement and cost reduction eventually reached a point where further gains were no longer practical, and reimbursement structures penalized the very clinicians who were already delivering the most efficient and effective care.

Table 2.2026 CMS Specialty Models Launched
Program Core Structure Risk Design Specialist Implications
TEAM Mandatory episode-based program for select procedures, including joint replacement and spinal fusion. Retrospective reconciliation with upside/downside risk tied to episode cost and quality. Requires surgical pathway standardization, imaging governance, and site-of-service optimization.
ACCESS Multi-year specialty accountability program focused on chronic MSK pain. Prospective payments with performance adjustments tied to quality and utilization. Expands surgeon responsibility beyond procedures to encourage conservative care.
Ambulatory Specialty Model Emerging outpatient specialty program. Prospective Per Member Per Month (PMPM) + episode incentives. Shifts accountability to ambulatory MSK management requiring integrated data and governance.

Value-Based Care: Forcing a Paradigm Shift on Specialists

In a fee-for-service model, specialists are rewarded for procedural volume, service intensity, and downstream utilization, creating a “proceduralist” surgeon identity (Reindersma et al. 2022). As value-based models expand, MSK specialists will need to approach patient care from a broader, whole-patient perspective rather than focusing solely on the pathology. This means MSK surgeons must take greater responsibility for early triage, evidence-based standardized non-surgical and surgical pathway adherence, and population-level outcomes (Yee et al. 2020).

While value-based care is not new to specialists navigating today’s evolving healthcare landscape, limited time, resources, and poor access to timely and accurate clinical and claims data continue to be major barriers in taking a meaningful role in shaping and adapting to these models. Clinical governance requires resources and a patient-care mindset that were not historically necessary in a fee-for-service practice (Whitcomb et al. 2015; Hung, Simonson, et al. 2025; Carter Clement et al. 2017). These resources include technology to collect and interpret integrated cost and outcomes data, dedicated time and trained personnel to lead multidisciplinary teams and coordinate with upstream care providers, and the capacity to pilot and evaluate standardized, evidence-based care protocols. Without these supports, specialists face an almost impossible task in trying to succeed within value-based arrangements.

Once specialists are equipped with the resources to define and lead value-based protocols, the deeper paradigm shift emerges: MSK surgeons must now make decisions that influence the full journey of care rather than simply identifying and treating the pathology within a surgical episode (Whitcomb et al. 2015; Hung, Simonson, et al. 2025; Carter Clement et al. 2017). The natural tendency of surgeons is to act, yet true value-based care requires a more deliberate approach of assessing, managing, and guiding patients in ways that prioritize avoidance of unnecessary diagnostics or surgical intervention.

Early experience from specialty-led models in cardiology, oncology, nephrology, and emerging MSK networks demonstrate that when specialists influence and oversee the full care continuum, total costs of care decrease and patient outcomes improve (Liu 2023; Curtis et al. 2015; Brenne et al. 2021).

The Case for Specialist-Led Care

Specialist-Led Care is emerging as a necessary model in response to the need for MSK surgeons to take a larger role in care transformation. As mandatory value-based models expand, the need for governance by clinicians with the appropriate level of expertise becomes increasingly clear.

The concept of Specialist-Led Care centers on aligning pathway design, triage, and resource decisions with MSK surgeons. Rather than creating another prescriptive program, Specialist-Led Care proposes a shift in orientation: MSK surgeons guide the care journey from the outset to reduce variation, improve predictability, and ensure that decisions reflect clinical patient care reality rather than administrative process (Massel et al. 2026; Rana et al. 2023).

Orthopaedic and spine surgeons are uniquely positioned to lead this evolution because they sit at the point of influence that defines downstream treatment pathways and resource utilization. Their decisions determine imaging, therapy progression, injection sequencing, site-of-service selection, and surgical utilization, each of these being a major driver of cost and variation. As previously noted, when specialists lead early triage and pathway governance with visibility into the entire care journey, avoidable utilization can be reduced, and evidence-based conservative care pathways be defined and followed (Dlott and Wiznia 2022).

A total-cost-of-MSK-care at-risk model creates accountability for the full patient journey rather than isolated procedures or episodes of care. Importantly, it enables MSK specialists to work upstream with primary care clinicians, therapists, digital care teams, and other referring providers to improve early triage, diagnostic decision-making, conservative care sequencing, and the timing of specialist involvement. This collaboration helps ensure that patients enter the appropriate care pathway sooner, while avoiding unnecessary imaging, duplicative services, prolonged low-value treatment, and preventable escalation of care. Once specialty care is required, physician-led governance can further improve surgical appropriateness, site-of-service selection, post-acute utilization, and longitudinal recovery. With integrated data, aligned incentives, and shared clinical pathways, population-level risk supports the rightsizing—not simply the reduction—of total MSK cost by directing resources toward the care most likely to improve patient function and outcomes.

Early experience from specialty accountability models reinforces this approach and markets developing specialist-led clinically integrated networks (CINs) demonstrate early success in aligning specialists around standardized pathways and total cost of care management (Scalise and Jacofsky 2017; 2018a; 2018b).

Table 3.Musculoskeletal Total Cost of Care and Quality Drivers
Cost Driver Care Delivery Requirements Specialist Responsibilities
Care Pathway Selection Ensure patients receive the necessary care at the right time from the right provider. Specialists determine diagnosis, imaging needs, and surgical candidacy.
Conservative Care Sequencing Standardize PT, injections, medications, and escalation timing. Prevent inconsistent or prolonged conservative care.
Imaging Stewardship Reduce unnecessary MRI/CT use and wasted spend in high-cost settings. Determine when imaging is clinically necessary.
Site-of-Service Optimization Shift appropriate patients and cases to lower-cost settings. Establish strict outpatient selection criteria.
Post-Acute Care Management Manage SNF, home health, and inpatient rehab use and therapy intensity. Standardize discharge planning process.
Longitudinal Outcomes Track functional recovery and recurrence. Intervene early when recovery deviates.
Population-Level Accountability Manage MSK cost and quality across a population. Continuously refine care pathways to reduce cost and variation.

Structural Resources Needed to Enact Specialist-Led Care: MSK-focused Clinically Integrated Networks (CIN)

Specialist-Led Care requires infrastructure that supports clinical governance, comprehensive data collection and analysis, standardized pathway development, and longitudinal patient care accountability. Building this infrastructure is not a rapid undertaking; it demands sustained investment of time, resources, and organizational commitment. Meaningful implementation depends on leaders who believe MSK care can be delivered in a more coordinated, evidence-driven way than current models allow. Establishing this foundation requires patience, disciplined leadership and execution, and a long-term dedication to transforming how MSK patients move through the care continuum.

Evidence from clinically integrated and accountable care networks demonstrates their potential to improve cost, utilization, and clinical performance (Reindersma et al. 2022; Leao et al. 2023; Teisberg et al. 2020; Speerin et al. 2014). MSK-focused, physician-led clinically integrated networks (CINs) provide a practical structure for translating specialist expertise into population-level value. Unlike broad delivery models in which MSK decisions may be governed primarily through administrative rules, these CINs place orthopaedic and spine physicians in leadership roles over clinical pathways, appropriateness standards, and utilization management. With integrated data and analysis, care coordination, and aligned incentives, physician-led CINs can influence the full MSK care journey from early triage and conservative care through imaging, surgery, site-of-service selection, and recovery. This approach reduces unwarranted variation while preserving individualized clinical judgment and specialist accountability. It also provides payors and employers with a clinically credible partner capable of managing quality, outcomes, and total cost of MSK care across a population. In this way, physician-led CINs offer the governance and operating infrastructure necessary to make specialist-led value-based care scalable and sustainable.

Table 4.Specialist-Led Care Structural Requirements (Advisory Board 2026)
Requirement Core Function Impact
Integrated Data Infrastructure Access to cost, utilization, and outcomes data for all MSK services. Enables regular reporting and analytics, variation management, and pathway governance.
Standardized Clinical Pathways Evidence-based protocols for conservative care, imaging, injections, and surgery. Reduces unwarranted clinical care and variation.
Care Coordination Resources Navigators, triage teams, centralized scheduling. Ensures efficient pathway progression.
Clinical Governance Specialist-led review of imaging and other MSK interventions. Reduces avoidable utilization.
Site-of-Service Optimization Criteria for shifting cases to ASC/office-based procedure and imaging settings. Lowers cost while maintaining quality.
Population-Level Contracting Capability Ability to participate in PMPM cost, episodes of care, and other specialty models. Allows surgeons to capture value created across entire MSK care journey.

Risks of Inaction: If Surgeons Do Not Lead

Failing to enact a Specialist-Led Care model exposes orthopaedic and spine surgeons to escalating clinical and financial risk as well as unnecessary administrative burden. Without specialist governance, non-clinical entities will determine care pathways and appropriateness criteria, narrowing surgeons’ ability to direct evidence-based patient care. This reduction in autonomy could place surgeons in a reactive position, where decisions that shape patient flow, resource allocation, and long-term outcomes are made without their direct input.

The absence of specialist leadership has the potential to destabilize care delivery and heighten the specialists’ vulnerability to administrative and reimbursement processes that do not align with true evidence-based care.

These dynamics illustrate why Specialist-Led Care is essential, not only for preserving clinical authority, but for ensuring MSK care remains predictable, efficient, and aligned with value-based expectations.

Framework for Implementing Specialist-Led Care

The transition to Specialist-Led Care begins with recognizing that successful models exist and have demonstrated meaningful improvements in MSK value. What remains is understanding the structure that allows those models to function: the governance, processes, and operational supports that make specialist leadership possible. This section outlines the framework needed to move from a traditional fee-for-service model into Specialist-Led value-based Care.

A broader set of programs is emerging beyond procedure-based bundles, including MSK-focused CINs, payer-provider MSK population health arrangements, employer-sponsored MSK programs, and specialty accountability models that combine clinical governance, care coordination, data analytics, and shared responsibility for total MSK cost and outcomes. These approaches have shown that specialist involvement across the full MSK care continuum can improve pathway adherence, reduce unnecessary imaging and low-value utilization, shift appropriate care to lower-cost settings, and support earlier recovery. These programs apply physician-led governance across the entire MSK care journey for a population, including nonsurgical and upstream care. Over the last several years, an expansion of this approach is emerging through MSK-focused networks that connect specialists, primary care providers, health plans, and care-management infrastructure around standardized pathways and total MSK cost accountability. Although population-level evidence is still emerging, these models provide a practical foundation for expanding proven surgical episode-based principles across the broader MSK care continuum.

For MSK specialists to become effective champions of population-based MSK cost-of-care models, clinical leadership must be supported by substantial infrastructure. Required capabilities include integrated claims and clinical data, advanced analytics, standardized pathways, patient navigation, utilization management, outcomes measurement, risk analyses and payer contracting, financial reconciliation, regulatory support, and coordination across primary care, therapy, imaging, specialty, surgical, and post-acute services.

Building and maintaining this infrastructure is highly resource intensive and generally extends well beyond the operational capabilities of a traditional orthopaedic or spine practice. Rather than attempting to recreate these functions independently, specialists should consider partnering with an established, physician-led MSK value-based care organization or clinically integrated network. The right partner can provide scalable technology, risk assessment, contracting, analytics, and care-management support while preserving specialist authority over clinical standards, appropriateness, and the design of patient care pathways.

Table 5.Specialist-Led Care Framework
Component Impact
Governance: Specialist-led oversight of care pathways and utilization. Ensures clinically driven standards and reduces variation.
Clinical Infrastructure: Standardized pathways and longitudinal care management. Improves predictability and reduces unnecessary utilization.
Financial Alignment: Specialists share in the savings they create. Rewards quality and efficiency across the entire MSK care continuum rather than procedural volume and intensity.
Technology Integration: Risk tools, analytics, outcomes tracking. Enables proactive population-level management.
Market-Specific Tailoring: Customization to referral patterns and payer mix. Improves adoption across diverse markets.
Scalable Operational Support: Infrastructure to manage PMPM cost, episodes of care, and MSK TCOC models. Allows participation in multiple risk models.

Conclusion

Value-based care and the steady shift toward population-level management are not going away. Orthopaedic and spine surgeons face a choice: lead the redesign of MSK care delivery or become proceduralist commodities with shrinking autonomy and a declining reimbursement landscape.

Specialist-Led Care offers a clear path forward. By embracing clinical governance across the full care continuum, surgeons can reclaim their central role in defining high-value MSK care. When clinical leadership is paired with real-time data, operational support, infrastructure and resources, and aligned incentives, Specialist-Led Care becomes both feasible and transformative.

MSK surgeons must take their seat at the table or be swept along by a value-based care tide shaped without their input. The redesign of musculoskeletal care is underway, and the time to lead is now.