Value-based Healthcare: How Value-based Care Can Improve Access and Limit Disparities for Musculoskeletal Patients in Underserved Communities

In the United States, Hispanic and Black patients face longer delays in receiving important musculoskeletal surgical procedures [6, 9] and undergo THAs and TKAs at lower rates than their White counterparts [7, 8]. These disparities disproportionately affect underserved communities, where higher rates of physically demanding jobs, limited health literacy, and financial constraints exacerbate barriers to timely care for musculoskeletal conditions. As a result, patients in these communities often experience prolonged pain, reduced mobility, and a greater financial burden because of missed work and disability. Without targeted interventions, these inequities will continue to widen, leaving under-resourced populations without the musculoskeletal care they need to maintain their quality of life.

These structural disparities are compounded by the fee-for-service model, which prioritizes volume over health outcomes and limits the availability of timely musculoskeletal care for patients who lack insurance as well as those with Medicaid, who are disproportionately part of marginalized communities [1]. By the time they receive care, these patients often present with more advanced symptoms, resulting in more complex and costly interventions. These delays not only lead to worse functional outcomes and prolonged discomfort but also perpetuate financial strain on both patients and the system. Addressing these structural barriers through value-based initiatives that prioritize access and early intervention is essential to improving musculoskeletal care for historically marginalized communities. Throughout this column, we will describe multiple value-based initiatives that may improve access to care and health outcomes for patients with musculoskeletal conditions, particularly those from under-resourced communities.

Bundled Payment Models

One major barrier to healthcare access in resource-limited communities is cost. Many patients rely on Medicaid insurance or are uninsured, which limits physician reimbursement and availability. This often leads to delayed or fragmented care, thereby worsening health disparities. An alternative payment model is needed to improve access, reduce financial strain, and ensure continuity of care, and longitudinal condition-based payment models (LCBPMs) offer a potential solution.

LCBPMs provide a single, fixed payment for the management of chronic conditions, such as osteoarthritis or back pain, for a defined period of time. For instance, the Musculoskeletal Institute at UT Health Austin has implemented an LCBPM for the management of all musculoskeletal conditions for one year, including all professional services delivered by the care team during that period [1]. This model reduces unexpected medical expenses, minimizes gaps in treatment, and improves patient outcomes through better care integration, thereby eliminating some of the barriers that often compel patients to let their conditions go untreated and rely on emergency care services instead. Additionally, by promoting collaboration among clinicians across the entire continuum of care, LCBPMs can address social determinants of health, such as transportation challenges, housing insecurity, and access to follow-up care, which further improves long-term health outcomes. By focusing on health outcomes achieved per dollar spent to achieve those outcomes rather than on the volume and intensity of services provided, LCBPMs align financial incentives across all stakeholders involved in the continuum of care in a way that encourages the deliverance of high-value, preventative care for socially and economically marginalized groups.

Integrated Practice Units

Integrated practice units (IPUs) help address disparities in access and outcomes by organizing multidisciplinary teams around common medical conditions. This patient-centered approach can address the cultural, socioeconomic, and mental health factors faced by disadvantaged populations while they are seeking care for a musculoskeletal condition. In the case of musculoskeletal care, these teams include clinicians with diverse training backgrounds—such as physical therapists, social workers, dietitians, advanced practice providers, and orthopaedic surgeons—who manage a patient’s entire care cycle collaboratively. By working in the same space, sharing data, and collaborating on care plans, these teams enhance care continuity, decrease disruptions in recovery, and decrease workload on individual physicians. Patients benefit from seeing various types of clinicians during a single visit at one location, potentially decreasing the number of follow-up visits required and the burdens associated with attending additional appointments. Improving access to various types of care for disadvantaged populations, in turn, reduces their need to seek care at tertiary centers, like emergency departments, for musculoskeletal issues. As a result, IPUs not only improve the value of musculoskeletal care but also ensure more equal access to high-value care. Finally, IPUs can accommodate more new patients than traditional fee-for-service models because each care team member can focus on the most complex tasks they are trained to do rather than rely on physicians to perform time-consuming duties that other clinicians are qualified to handle.

Patient-reported Outcome Measures

Historically, clinical guidelines and outcome measures have been based on data from predominantly White, higher-income populations, failing to capture the unique experiences and challenges faced by other populations [2, 5]. Patient-reported outcome measures (PROMs) help bridge this gap by allowing patients to report their own experiences with pain, function, mental health, and overall well-being. PROMs offer insights beyond traditional clinical metrics while ensuring that patients’ symptoms, concerns, and treatment goals are not overlooked.

By integrating PROMs routinely into musculoskeletal care [3, 4], clinical teams can track progress over time and tailor treatments to individual needs rather than relying on benchmarks that may not represent diverse populations. For example, pain perception and functional limitations may vary across different racial and socioeconomic groups because of differences in access to early intervention, occupational demands, or social determinants of health. Without PROMs, these variations may go unnoticed, leading to inequitable care. By systematically collecting and analyzing these data, clinicians can identify disparities in treatment responses and adjust management strategies accordingly. PROMs also strengthen communication between clinicians and patients, empowering individuals to take an active role in their treatment.

In underserved communities, where mistrust of clinicians is often rooted in historical injustices and ongoing disparities, actively incorporating patient-reported data into clinical care shows these patients that their voices matter. Additionally, use of PROMs enhance adherence to care plans [10], as patients are more likely to engage with treatment strategies that reflect their experiences and priorities. By capturing and addressing the unique experiences of overlooked communities, PROMs help ensure that all patients, regardless of race, ethnicity, or socioeconomic status, receive care that is both effective and just.

Potential Challenges

A key challenge in implementing value-based care is the current payment models and policies, which often prioritize volume and intensity of services over health outcomes. To address this, we must first redefine the role of musculoskeletal physicians and the tools needed to care for patients. Physical, mental, and social health are interconnected, particularly in low socioeconomic status communities, where chronic pain, limited access to rehabilitation services, and socioeconomic stressors often exacerbate musculoskeletal conditions. Musculoskeletal care should reflect this reality by incorporating patient-centered approaches that extend beyond procedural interventions. This means integrating mental health support, addressing social determinants of health, and ensuring culturally competent care delivery. By incorporating mental and social health into their practices, physicians will note improved outcomes with decreased overall costs in their practices. This evidence can be presented to payers as leverage to improve the payment model by incorporating these services into the overall payment model.

One way to integrate these principles into musculoskeletal care is through LCBPMs. However, implementing LCBPMs in musculoskeletal care presents several challenges. Physicians take financial risks if treatment costs exceed the fixed payment, which can discourage clinicians from taking on patients with complex problems. Additionally, payers may resist change without clear evidence of cost savings. There is also a risk of cherry-picking healthier patients if reimbursements do not account for social and medical complexity. Ensuring that LCBPMs account for these factors is essential not only for their success, but also for advancing equal treatment in musculoskeletal care. Without these safeguards, the patients who stand to benefit the most—those with complex medical and social needs—may continue to face barriers to timely, high-quality treatment.

Implementing IPUs also poses challenges. Establishing IPUs requires substantial upfront investment in physical infrastructure, shared electronic health records, and multidisciplinary staffing, which many practices lack. Additionally, fee-for-service reimbursement structures often do not cover core IPU activities like care coordination or services provided by nonphysician team members. Without value-based payment models, sustaining IPUs financially can be difficult. These limitations can restrict IPU implementation in the communities that stand to benefit most from this model.

A Way Forward

Addressing disparities in musculoskeletal care starts with individual action. A simple yet impactful step is assessing how much of your patient population comes from a disadvantaged background. Understanding the specific financial, logistical, or cultural barriers our patients face allows us to tailor care more effectively. Incorporating PROMs can further enhance this effort by systematically tracking what matters to patients from their perspectives, ensuring that treatment plans reflect each patient’s expectations and experiences.

Beyond the clinic, we can take specific steps to prevent symptoms from worsening in underserved populations. Promoting early intervention and nonoperative management strategies can help patients avoid costly and complex procedures down the line. Additionally, establishing strong partnerships with primary care physicians in the community can improve referral pathways, streamline care coordination, and ensure patients receive timely musculoskeletal treatment. Engaging with health plan administrators to explore LCBPMs or IPUs can help shift the focus from volume-based care to a more sustainable, patient-centered approach. These models will not only improve value but also ensure that low socioeconomic status populations receive the comprehensive, coordinated treatment they deserve.