Gatekeepers vs. Gateways: Who Owns the Patient Care Journey?
And at What Cost?
Traditionally, musculoskeletal care follows a relatively linear path:
A patient with joint, spine, or muscle pain sees their PCP. The PCP attempts initial management but eventually refers to an orthopedic surgeon. The surgeon offers treatment of variable value, quality, and effectiveness.
Doctor, patient, payor, and employer all define success differently. Spending increases, and there’s little transparency around costs or outcomes.
But challenges create opportunities.
Today, many alternative care models aim to change who controls patient access to MSK care. The rise of digital MSK platforms, primary care-focused VBC models, and navigation services is challenging the role of orthopedic surgeons as stewards of MSK treatment.
The front door to MSK care is suddenly very crowded. The goal of these new players is to reduce costs and unnecessary interventions by shifting the gatekeeping role away from specialists. Virtual PT startups, risk-bearing PCPs, employer-approved care coordinators, and others seek to intermediate care in the name of value.
Is all this added gatekeeping really in the patient’s best interest—or are we just replacing one set of perverse incentives with another?
In the battle to control MSK care, who owns the patient care journey? More importantly—who should?
The New Gatekeepers
Over the last several years, there's been an aggressive push from digital health companies, CMS, and navigation services to intermediate specialty care, including:
Virtual MSK companies like Hinge Health and Sword Health that promote easily accessible, clinically robust, cost-reducing digital-first PT models.
CMS and CMMI value-based models like ACO REACH and TEAM which financially incentivize PCPs to take ownership of specialty care—including MSK.
PT-first advocacy groups who argue that physical therapists should be the low-cost default entry point for MSK care (instead of ortho surgeons).
Navigation platforms like Transcarent and Carrum Health that work with employers to redirect patients to curated, high-value networks of specialists and facilities.
Each of these entities aims to subvert orthopedic surgeons and act as the new gatekeepers of musculoskeletal care. Their common claim is that orthopedic surgeons are expensive and quick to operate—offering low-value interventions to arbitrage a fee-for-service system that rewards volume over value. Intervening upstream in the specialty care pathway is their answer to controlling rising MSK costs.
In theory, steering patients to less invasive treatments and lower-cost alternatives improves costs without sacrificing outcomes.
But is that really the case?
Steering Patients Away from Ortho
One of the clearest examples of intermediation is Hinge Health’s HingeConnect— software designed to scrape medical records for intervention opportunities. The goal is to identify MSK-related diagnoses early and divert patients away from orthopedic surgeons toward virtual PT and digital coaching.
Per the company, “EMR data from 750,000 providers across 71,000 care sites is proactively monitored to identify opportunities to offer less-invasive care by flagging select orders, such as surgery referrals or opiate prescriptions.”
Depending on your point of view, HingeConnect is either a brilliant way to ensure high-value, evidence-based treatment or a subversive attempt to dictate care without accepting real clinical risk.
Either way, this approach raises several questions:
Is the intent to improve patient care or justify ROI by controlling referrals?
Do these interventions prevent unnecessary surgeries or just delay definitive care?
Without longitudinal outcomes data, how do we know patients are actually getting better?
If these companies are making triage and treatment decisions with limited information, should they also be responsible for downstream consequences?
Hyper-avoidance of specialist input has risks. Medical expertise comes from years of training and real-world experience that’s not easily replicated. Proper evaluation and informed clinical decision-making ensure good outcomes. Early surgical intervention is high-value treatment for select patients. Delaying appropriate care (surgical or otherwise) is low-value—full stop.
It would be disingenuous to suggest that orthopedic surgeons always deliver evidence-based, high-value care. But, assuming that keeping patients away from specialists qualifies as a “win” is equally fallacious. The goal should always be to offer the highest value treatment given the individual patient’s circumstances. Again, inappropriate care is low-value, no matter the gatekeeper.
It’s easy to point fingers, but are specialists really the problem?
The Low-Value Care Debate
One of the most common arguments from digital MSK platforms and value-based care advocates is that traditional MSK care is plagued by low-value interventions:
Too many imaging studies, injections, and unproven treatments
Too many unnecessary surgeries
Highly variable specialist care quality
Underuse of less expensive, equally effective modalities like PT and health coaches
Overly aggressive, non-evidence based MSK treatment is certainly an issue. Studies suggest that as many as one-third of total knee replacements may be performed inappropriately—typically on patients with symptoms too mild to warrant surgery.
According to a Lown Institute study, unnecessary back surgeries cost Medicare around $600 million dollars annually ($2 billion and 200,000 procedures over a three-year period). Some of these surgeries lead to poor outcomes, continued disability, and significant long-term consequences like chronic opioid use.
But what about the other side of the value equation? What’s the cost—clinical and financial—of delaying appropriate treatment?
Studies suggest we’re underestimating this cost:
In one major RCT, 74% of patients with moderate knee arthritis avoided surgery for at least a year with structured PT…but the surgical group had significantly better outcomes.
A 2021 analysis found that delaying knee replacement indefinitely may sacrifice meaningful years of function and reduce quality of life. The study concluded that earlier TKA is cost-effective in younger patients with advanced knee arthritis.
For degenerative lumbar conditions, waiting longer than 6 months to have surgery reduces the likelihood of achieving clinically important gains, according to a recent study.
Again, the goal is to do the right thing for the patient. Our old friendly cliche—right patient, right treatment, right time—holds true. However, it’s wrong to assume there’s no cost to universally pushing less-invasive care first. Rather than dogmatic thinking, the key is figuring out what’s high value and what’s low value based on the situation.
But who’s best positioned to make that determination?
Are All Gatekeepers Created Equal?
The battle to control care decisions rages on with lines drawn between PCPs in value-based care models, healthcare startups trying to prove ROI, and specialists arguing it should be them. Each side argues that they’re best positioned to guide care decisions with the patient’s best interests in mind. Who’s right?
The data provides some clues:
A study of 2,000 working-age primary care patients found that 60% sought care for musculoskeletal disorders—yet 13-35% of those patients were never formally diagnosed. There was wide variation in how cases were managed and inconsistencies in evaluation and treatment. These findings suggest that primary care may not be adequately equipped to serve as the MSK front door, leading to misdiagnosis, inconsistent management, and delayed access to definitive care.
A comprehensive review of global MSK care models found that primary care-led triage often results in suboptimal diagnosis, unnecessary imaging, and fragmented treatment—in part because many PCPs lack musculoskeletal training and confidence. The authors emphasize that simply swapping gatekeepers isn’t enough—effective care requires integrated, evidence-based processes that prioritize speed, precision, and patient outcomes.
While virtual MSK platforms are convenient and cost-effective for low-acuity problems, they lack the diagnostic depth and nuance of in-person assessments. Studies suggest virtual exams may miss certain findings, and triage decisions made without hands-on evaluation or imaging can delay appropriate care. (Liability remains a concern, too, with 66% of telemedicine-related claims between 2014 and 2018 related to a misdiagnosis).
A study of ~400 VA patients with chronic low back pain or knee osteoarthritis compared outcomes and costs between care delivered by generalists, specialists, or a combination of both. Specialist-only care provided greater functional improvement at a modestly higher cost, while co-managed care (specialist + PCP) was significantly more expensive and delivered the least improvement. The study concluded that specialist-led care was more cost-effective than non-specialty care and far more efficient than fragmented care models.
These studies lead to one conclusion—high-value care is best provided by specialists who know how and when to intervene. This isn’t to say that current specialty care models are perfect or that collaborating and coordinating care has no value. (We’ll get to that shortly).
Artificial intelligence will have a role to play here, too—not as a doctor replacement, but as a tool to enhance decision-making and personalize treatments. The rush to use AI as justification for care intermediation needs to be tempered with the reality that the tools aren’t ready for primetime.
No matter who drives care decisions—AI, specialists, PCPs, startups, or otherwise—the proof is in the outcomes.
But who’s held accountable?
Who’s Responsible for Outcomes?
It’s taken at face value that alternative approaches lead to less expensive, more evidence-based care compared to the traditional system. But, if virtual PT companies, navigation platforms, or PCP in capitated models want to act as MSK gatekeepers, they should also assume the risk for patient outcomes.
No system is perfect or free from abuse. The perverse incentives of value-based models include cherry-picking/lemon-dropping and inappropriately delaying needed care. While would-be gatekeepers point to per-member savings, short-term pain score reductions, and other similar metrics, they lack clarity on meaningful functional improvements and long-term outcomes.
Some of this is an unfortunate byproduct of how our system is structured. Employers and payors are short-term thinkers, focused on year-over-year medical spend. While clinicians think longitudinally and long-term. In musculoskeletal care, 5-year outcomes are considered “short-term.” In the employer benefits space, 5 years is an eternity. The problem is that short-term wins can turn into long-term losses.
There are real downsides to delayed or inappropriate care:
If a navigation service diverts a patient outside their community, and the Center of Excellence declines treatment, what happens to that patient? Despite the prevalence of such centers, we still don’t know the answer to this question.
If a virtual PT program keeps a patient in a loop of failed conservative treatment when surgery is clearly indicated, should those providers be held liable for the costs and complications of that delay?
If a triage algorithm is too sensitive, will it over-diagnose and paradoxically increase specialist referrals? If it’s too liberal, will it under-diagnose and cause harm?
Right now, surgeons are held accountable for patient outcomes—through complications data, public reporting metrics, and professional standards. Specialists don’t have the benefit of punting when things go south. While the future of MSK VBC is uncertain, CMS continues to move forward with models that tie reimbursement to patient-reported outcomes measures (PROMS). Commercial payors are expected to follow suit.
(Side note: Ignore cynics who claim surgeons financially benefit from their complications. The emotional and mental toll of a poor outcome is far outweighed by any monetary “reward.”)
When care is controlled by a startup company, AI-driven triage tool, or value-focused PCP, who takes responsibility for outcomes and owns risk? Startups may take a degree of financial risk through pay-per-click or shared savings models. But that’s different than accepting risk for a poor clinical outcome or treatment complication.
I’ve advised several companies developing triage tools meant to steer patients to the most appropriate care pathway. It’s not easy—especially with the limitations of virtual data collection. These companies want to do right by patients, which often means defaulting to the most conservative approach: when in doubt, refer.
The same problem exists in VBC models that incentivize PCPs to avoid specialist care. Do capitated models really punish late referrals, missed diagnoses, or inappropriate care? Maybe—but it’s highly dependent on how the model is constructed.
Many outsiders skirt liability, positioning their services as informational and supportive—not meant to diagnose or treat. This “have your cake and eat it too” approach raises ethical and clinical concerns. Oversight of digital health remains an open question. Some have suggested corporate backers take the Hippocratic Oath. Regardless, intermediating care should come with some liability for risk and outcomes.
How do we create a system that encourages ownership and responsibility?
The Right Model: Smarter, Faster, Patient-Centered MSK Care
The real solution to MSK inefficiencies isn’t replacing one gatekeeper with another—it’s about precision triage, high-yield clinical pathways, and tightly integrated care.
I’ve written before about using MSK care as the gateway (not gatekeeper) of holistic care and the need for a decentralized, distributed hub-and-spoke model. These concepts overcome the limitations of gatekeeping and lead to smarter, faster, patient-centered MSK care.
Here’s why they work:
Placing patients on the correct treatment path immediately through comprehensive, holistic assessment informed by deep expertise.
Avoiding waste and unnecessary steps, whether that’s excessive PT for end-stage arthritis or unnecessary MRIs for routine back pain.
High-value decision-making and knowledge-sharing across the care continuum, rather than arbitrarily restricting access to specialists.
High-quality, efficient, transparent micro-Centers of Excellence that deliver cost-effective next-generation specialist care.
Hubs synthesize data and coordinate the patient journey, reducing fragmentation and taking responsibility for long-term outcomes—longitudinal care matters.
The alternative to gatekeeping is ownership.
The most effective MSK care models won’t rely on dogmatic avoidance of specialists or forcing patients into rigid care pathways. Instead, they’ll offer one-stop holistic care where the entire journey is delivered through a comprehensive, integrated model.
We’re beginning to see such next-gen MSK care models emerge—models that reject gatekeeping in favor of ownership, integration, and longitudinal value creation.
Such models ensure:
Patients get the right diagnosis from the start
Conservative care is evidence-based, appropriate, and carefully monitored
Invasive treatments, including surgery, are offered in a timely fashion when clinically indicated
Long-term outcomes are tracked and optimized across the full condition-based episode
Real vertical integration in healthcare isn’t about revenue capture; it’s about creating better processes. Such a model is achievable, not theoretical. The goal isn’t to gatekeep care—it’s to optimize for value, quality, and patient experience.
Final Thoughts
At its core, the gatekeeping debate is about who owns the patient journey. The push to redefine MSK care pathways is being made under the guise of reducing costs. Virtual care companies, care navigators, and VBC PCP models subvert specialists in the name of value. But, we lack clear evidence that these efforts improve long-term patient outcomes and deliver sustainable cost savings.
Like it or not, each gatekeeper has their own set of incentives.
The right approach is about creating gateways, not gatekeepers. It’s a system built for efficiency, accuracy, and high-value care. One that optimizes access to high-yield care at the appropriate time—without unnecessary delays or shifting incentives from one financially motivated group to another.
It’s about ownership, not intermediation.
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
BUYER BEWARE: INEPT MDS & BAD DISKS
The two biggest clues your MD uses “outdated models of care” based on “widespread misconceptions” occurs when patients are not referred to chiropractors immediately. Most MDs deceived patients by not confessing spinal problems are outside their scope of expertise because, in fact, most MDs are inept according to many medical experts themselves. Today the consensus agrees primary care physicians lack training in musculoskeletal disorders (MSDs), are more prone to ignore recent guidelines, more likely to suggest spine surgery than surgeons themselves, and only 2% of primary care physicians (PCPs) refer to DCs as a nondrug treatment despite the superior training and results.
Richard Deyo, MD, MPH, author of “Watch Your Back!” also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments:
"Calling a [medical] physician a back pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."
Scott Boden, MD, currently director of the Emory Orthopaedic and Spine Center in Atlanta, also warned of this fiasco years ago in 2003 in an article in Spine when he admitted:
“Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”
“As anyone who follows medical news is aware, excessive prescription of opioids for back and other forms of chronic pain has prompted a destructive epidemic of overdoses and deaths, with more than 17,000 deaths per year. And the opioid overtreatment epidemic has in turn kicked off a terrible wave of heroin addiction and overdose deaths.
Physician must maintain a medical license, be credentialed by their hospital and all payers, and submit their notes to third parties to ensure their treatment plans are appropriate (Prior authorization). Hinge and others avoid all these requirements even though they are practicing medicine. These companies avoid liability by not creating patient records, not having a physical address, and not having a provider ( just a health coach and AI algorithm). If COVID had not relaxed all our telehealth laws, state medical boards would have stopped this corporate practice of medicine by unlicensed health coaches and AI tools. Uber broke the taxi medallion, but I doubt DTx will break medical licensure.