Escaping the Black Hole: A Smarter Path for Specialty Care

Presented by Commons Clinic

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Musculoskeletal care is often cited as a microcosm of healthcare’s systemic dysfunction — low-value treatments, misaligned incentives, spiraling costs, and highly variable quality. My specialty is fraught with opacity, inefficiency, and information asymmetry, which makes it difficult for patients, primary care providers, employers, and health plans to identify and access high-value MSK treatment.

The problem is big and growing.

For this week’s edition of The Surgeon’s Record, I’m revisiting a post I wrote last year — “Case Study in MSK Value: Cascading Failure”—that highlighted these issues through a fictional patient journey. As I head to the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in San Diego this week (where I’ll be moderating a session on this very topic), it feels like the perfect time to revise and update the post.

What’s changed?

The core message of my original article still applies. Navigating between primary and specialty care remains an exercise in inefficiency, waste, and frustration for all involved. Last year’s article presented a solution — my vision for high-value MSK care as an "achievable pipedream."

A year later, I’m now convinced that high-value, high-quality, next-generation specialty care is no longer a pipedream — it’s already here.

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The MSK Care Conundrum: Fragmentation and Frustration

The following is a fictional case presentation, but one that plays out in medical offices every day across the country.

Mya is an active 58-year-old female who develops knee pain while playing pickleball. As the system intends, she starts with her primary care physician, who—uncertain of the best approach—orders both an ultrasound (to rule out a blood clot) and non-weightbearing “trauma” knee x-rays.

Since Mya’s PCP recently consolidated into a large health system, her imaging is scheduled at the local health system, resulting in a facility fee and higher costs.

The x-ray report mentions mild arthritis and a benign bone mass, prompting an MRI for further evaluation. The MRI details multiple findings of unclear significance. The Radiology report lists 10 separate bullet points, causing Mya to anxiously wonder if something is seriously wrong with her knee.

Her PCP, equally uncertain how to interpret the report’s findings, refers her to an orthopedic surgeon within the health system. Instead of waiting months for an appointment with the employed specialist, Mya decides to see an out-of-network (read: higher co-pay) orthopedist instead.

This surgeon, unable to access her previous imaging, repeats the x-rays, this time using weightbearing views, which reveal more advanced arthritis than the prior non-weightbearing x-rays.

In a rushed visit (the surgeon is five charts and 90 minutes behind), Mya receives:

• A cortisone injection

• A prescription for anti-inflammatories

• Little discussion of other treatments (she’s told physical therapy likely won’t help)

• No explanation for the additional MRI findings

She leaves the office confused and uncertain about her diagnosis and prognosis.

Despite these treatments, Mya’s pain persists. The surgeon recommends arthroscopic surgery—an intervention of questionable value for knee arthritis. While the surgery is deemed a “success” by her surgeon, Mya’s knee pain and function worsen.

After months of ineffective, wasteful treatment, she undergoes a knee replacement.

By the end, Mya feels like a passive bystander, shuffled through an expensive system with little guidance, engagement, or clarity.

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The Failure Points

Mya’s case highlights fundamental flaws in specialty care pathways:

• PCPs are forced into low-value pathways, whether due to health system inefficiency, lack of resources, or practice pattern inertia.

• Specialists act on imperfect information, constrained by a failing FFS model to do more and engage less.

• Patients must navigate a complex system that punishes them for acting independently — financially and otherwise.

Three Major Problems with the Current System:

1. Lack of Clarity & Imperfect Information

   • In today’s consolidated world, PCPs refer based on health system mandates, habit, or availability. Independent PCPs rely on imperfect data and historical practice patterns. Quality and outcomes lack transparency.

   • Specialists don’t always have access to prior imaging or patient data, leading to duplicated tests, delayed care, conflicting recommendations, and wasted resources.

   • Patients are left frustrated and confused — paying more without gaining clarity.

2. Failure to Define & Deliver Value

   • FFS has its flaws, but a demonstrably better system has yet to emerge.

   • Specialists have little incentive to abandon FFS in favor of the financial uncertainty and administrative complexity of VBC.

   • Low-value interventions persist, while high-value clinical pathways remain difficult to implement and sustain.

3. Low Patient Engagement & Shared Decision-Making

   • Overwhelmed physicians spend too little time on education and shared decision-making.

   • Patients make underinformed choices, often subject to suboptimal treatment or experiencing inferior outcomes due to lack of engagement.

These criticisms aren’t theoretical — this exact scenario plays out daily on the frontlines. At its core, this is a "cascading failure"— a series of small but compounding system-level mistakes that increase costs, erode patient trust, and lead to inferior outcomes.

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Building a Better System

A next-generation specialty care model shouldn’t just fix one aspect of the problem—it should redesign the entire care journey.

Key Components of High-Value MSK Care:

• Low-Friction, High-Value Referral Pathways

  • PCPs need access to high-quality specialists with transparent, proven results.

  • Referrals should be based on trust and outcomes, not “brand name” assumptions of quality or systemic patient capture.

• Technology That Improves Coordination & Engagement

  • Imaging, clinical notes, and treatment plans must be seamlessly integrated across the care continuum.

  • Tech should extend care beyond traditional settings without adding barriers or complexity.

• Value as a Byproduct of Better Processes & Outcomes

  • Physicians should be rewarded for delivering high-quality, cost-effective, clinically-appropriate care — procedural and non-procedural.

  • Condition-specific models should balance VBC and FFS elements to ensure care models are fair and sustainable.

Mya’s Case—Revisited

For Mya (and others), a redesigned model that incorporates these elements means:

• Her PCP would have had immediate access to high-value MSK specialists.

• Her treatment would have been guided by best practices — immediate weightbearing x-rays that would have avoided an unnecessary MRI and months of ineffective treatment.

• Improved patient education and engagement would have ensured she understood her diagnosis, prognosis, and all treatment options.

• Shared decision-making would have led to the highest yield treatment and best outcome.

• If surgery was necessary, she would have been optimized for success, reducing risks, improving recovery, and providing access to the highest value surgeon and facility.

This model avoids low-value care, improves outcomes, and gives patients control of their healthcare decisions.

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The Future of Specialty Care

A year ago, I wrote that fixing MSK care felt like a pipedream. Today, I see it differently.

Over the past year, I’ve experienced firsthand how forward-thinking organizations like Commons Clinic are building clinically-integrated, technology-enabled MSK care models that solve these problems without adding complexity.

The dream of a better system is slowly taking shape. While it won’t happen overnight, much progress has been made since my original article last January. I’m excited to continue playing a small part both through this blog and leveraging my frontline experience to help build the future of specialty care.

Much more to come.

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Ben Schwartz, MD, MBA

Editor-in-Chief, The Surgeon’s Record

Commons Clinic Senior Clinical Fellow