How Can Primary Care Physicians and Orthopedic Surgeons Better Align Musculoskeletal Care

In his Value-Based Healthcare column featured in Clinical Orthopaedics and Related Research, Kevin Bozic, MD, MBA, the Chair of the Department of Surgery and Perioperative Care at Dell Medical School at the University of Texas, Austin, articulated the need for closer integration between primary and musculoskeletal care.

In this Consultant360 video Q&A, Dr Bozic discusses why meaningful progress in value-based care will require earlier, structured collaboration between primary care physicians and orthopedic surgeons, particularly in the upstream management of chronic musculoskeletal conditions such as osteoarthritis.

Key Highlights

• Earlier collaboration between primary care and orthopedics may improve chronic musculoskeletal outcomes and reduce unnecessary procedures.
• Cultural divides and misaligned payment incentives continue to limit shared accountability across care settings.
• Procedural episode models enhance perioperative efficiency but fail to address upstream chronic disease management

Additional Resources: Rubin I, Beckman A, Bozic KJ. Value-based healthcare: shared patients, shared risk-a call for integrating primary and musculoskeletal care. Clin Orthop Relat Res. 2026;484(2):238-240. doi:10.1097/CORR.0000000000003793

Transcript

Consultant360: What prompted you to write this column on the ways to integrate primary and musculoskeletal care?

Kevin Bozic, MD, MBA: My entire career, I've been passionate about delivery and payment models that align incentives between patients and clinicians. And I think that over the course of my career, I've seen how the payment model drives the delivery model, which contributes to moral injury in healthcare and has led a lot of clinicians to become disenfranchised. It's led to a dysfunctional healthcare system and patients to be marginalized in many cases. And so I've had this column really around value-based healthcare in general for over 15 years. One of the things that I've noticed during that time is sometimes the lack of interconnectedness between models that are aimed at influencing primary care and models that are aimed at influencing specialists. I would say most of the attempts to change the payment model and delivery model that organizes around value have been aimed at primary care. So primary care, medical homes, accountable care organizations, and specialists in many cases have been fee for service subcontractors, if you will, to those models. And I think that really disenfranchises specialists, but also does not leverage the expertise that specialists can bring in delivering, designing, and implementing different types of payment models that lead to better outcomes at a lower cost. I've always felt that the integration between primary care and specialty care is the next frontier and where we have the greatest opportunity to move the needle in value-based healthcare.

Consultant360: What are the biggest barriers to shared accountability between primary care physicians and orthopedic surgeons?

Dr Bozic: I think there are just some cultural barriers. Historically, primary care physicians have an incredibly difficult job. I have great respect for my primary care colleagues. They are really the front door for just about all healthcare problems that patients present with, and they have to be the experts in a myriad of different conditions. And it's really hard for them. It's hard enough for me as a specialist to keep up with my knowledge base in specialty care, let alone trying to do that across all of the different chronic conditions that patients present with. And so historically, what I've experienced in my 25-year career is that primary care physicians manage symptoms and conditions until they reach a point where they determine for a variety of different reasons that a referral to a specialist is appropriate. I think a lot of times there's a reluctance on the part of primary care physicians to refer out, especially if they're in an at-risk payment model, because once they refer to a specialist is when they start seeing diagnostic and therapeutic interventions going up, costs going up.

And so they really try to manage those conditions within the primary care model as much as possible. And I think that again, misses an opportunity to engage specialists in their knowledge in managing chronic conditions earlier in the process. So there's a cultural divide there. That's always been the case that primary care refers at a later stage when maybe the condition could have been managed different earlier. The other is just a very practical thing when you're talking about value-based payment models or at-risk payment models, concerns about double counting. If you're in a payment model where you are incentivized to reduce the total cost of care and you engage a specialist who gets credit for reducing the overall spend on management of osteoarthritis, for instance, is it the primary care? Is it the specialist? And whatever savings are created, you can't double count that and give both the primary care and the specialist credit. So somebody needs to get credit for that savings. And so that's also limited the interaction between primary care and specialty care. And as a result, most specialty care is still delivered through fee for service models, even if the primary care is based in an at-risk model like accountable care organization or a primary care medical home.

Consultant360: What practical steps can primary care physicians and orthopedic surgeons take to improve coordination even outside formal value-based models?

Dr Bozic: I think there's a lot of different ways. First of all, eConsult is something that became popular during the COVID pandemic and now is I think part of routine care. And so we have a really close relationship with our primary care colleagues, where they will send us an eConsult and say, this is the situation I'm dealing with. How would you recommend managing this? Do we need to order additional tests, imaging, et cetera? And so having that dialogue back and forth. And then I think as we get into models where we as specialists want to take risks for the overall management of these chronic conditions, referring earlier, and again, not because primary care doctors are not equipped to manage osteoarthritis or other primary conditions, but they can benefit from having the expertise of a multidisciplinary team that all they do is manage musculoskeletal disease and not waiting until the later stages, let's say when the patient might be a candidate for surgery, but actually getting a musculoskeletal medical home team involved earlier to maybe change the natural history or change the course of the disease and avoid surgery altogether. And so I think there's lots of opportunities from eConsult to having specialty care be part of the primary care model where the primary care physician engages the specialist early to where they can be responsible for managing those chronic conditions in close collaboration with their primary care colleagues. There's a variety of different ways to do that.

Consultant360: In your column, you highlighted the TEAM model. As models like TEAM rollout, what opportunities do you see for improving collaboration between primary care physicians and specialists?

Dr Bozic: What these episodic payment models, if you go back to BPCI (Bundled Payments for Care Improvement) and then CJR (Comprehensive Care for Joint Replacement) and other models, and now the TEAM (Transforming Episode Accountability Model) model have done is it's forced greater collaboration across the continuum of an episode of care, which in this case is a hip or knee replacement. The advantage of that is, again, is it forced greater collaboration and it can, for instance, make sure that patients are optimized before they undergo surgery. Anything that can be optimized from hemoglobin A1C to weight to mental health before going into a procedural episode is optimized. And then also on the back end that there's a better handoff between the proceduralists who do the procedure and the post-acute care that's resulted in some benefits to patients, less reliance on inpatient post-acute care, and certainly some very modest cost savings, but really hasn't moved the needle in terms of the way those conditions are managed or the overall cost of care or the outcomes.

And I think what's missing from models like TEAM is the focus on managing the condition to start with so that teams is, okay, we're going to do a procedure, let's make that procedure as efficient and cost effective as possible. It does nothing to address whether that procedure is the appropriate or best treatment for that condition in the first place. So what I see is the need to move upstream into payment models that incentivize optimal management of chronic conditions, in this case, osteoarthritis and greater integration between primary and specialty care and managing those conditions. So perhaps we can manage the condition in a way that we don't need to trigger a team's episode or a procedure, and that we're focused more on getting the right care to the right patient at the right time.

Consultant360: Are these types of models scalable, and where do health systems tend to struggle in that process?

Dr Bozic: They are scalable and it really, again, there's a cultural divide in that specialists tend to be in fee-for-service models. And so there's very little experience in putting specialists at risk for the management of chronic conditions. And I think the biggest barrier is both specialists and primary care physicians being willing to see specialists as part of managing those chronic conditions in a payment model that puts them at risk for both the cost and the outcomes. And so really looking for very common and expensive chronic conditions where there's a lot of variability in the way that they're managed and in the outcomes and total cost of care and osteoarthritis is one of those, diabetes is another, cancer is another, but picking conditions that are common that are expensive and that there's wide variability in that, the way they're managed and the outcomes and costs.

Consultant360: Is there anything else you would like to add or is there something we missed in the conversation?

Dr Bozic: I just think that value-based payment models have gotten a little bit of a bad wrap. And in part because things like procedural-based episodes were the focus and we probably squeezed a lot of the juice out of how to make procedures in 90-day or 30-day episodes more efficient. We didn't really move the needle that much in terms of the cost of those episodes, and we didn't move the needle at all in terms of the outcomes. And as a result, some payers and some health systems have lost enthusiasm for value-based payment models. I think again, what's missing there is the emphasis on stepping back and looking at the overall management of these chronic conditions and where we can bring that specialty care lens and the expertise that comes with specialists who spend their entire career in managing those conditions to bear in a way that gets us to better outcomes at a lower cost, and also is a more enjoyable and rewarding way for specialists to practice than just being brought in episodically around a procedure.

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