Self-insured Employers and Other Plan Sponsors Are Paying Millions for MSK (Musculoskeletal) Injuries That Would Have Healed Themselves, With Jay Kimmel, MD

Plan Sponsors Are Paying Millions for MSK Injuries That Would Have Healed Themselves — Here's Why

Musculoskeletal spend runs roughly $16 PMPM and accounts for 20–30% of total plan costs depending on member demographics — making it the third most costly category of spend. About 80% of those MSK injuries are low or medium acuity. A large percentage of those would heal on their own with ice, rest, and elevation. And yet plan sponsors are spending millions on ankle sprains.

In this episode, Stacey Richter speaks with Dr. Jay Kimmel, MD, an orthopedic surgeon with over 35 years of practice in Connecticut and co-founder of Upswing Health, about why so much low-acuity MSK spend is avoidable — and what it takes to catch a member in the "white space" before they wind up on the wrong trajectory.

WHAT YOU'LL LEARN

✅ Why 80% of MSK injuries are low or medium acuity but still generate massive spend: when members have no one to call in the moment they are injured, the default is the ER — and once they are sitting in an ER for six hours, they will demand an MRI, the MRI will find something (over-40 lumbar spine MRIs are full of false positives), and the referral cascade begins

✅ What the "white space" is and why it matters: the moment between "I just hurt myself" and "I am now a patient in the system" — when a member triages themselves with no clinical guidance; where they enter the system in that moment determines their entire downstream trajectory and cost

✅ How the state of Connecticut's claims data confirmed this: analyzing hundreds of thousands of state employee claims, Dr. Kimmel and his team found millions of dollars being spent with a diagnosis of ankle sprain — much of it unnecessary ER spend on injuries that would have resolved with basic self-care and guidance

✅ Why where you start often determines where you end up: a back pain patient who starts in the ER gets an MRI, the MRI finds incidentalomas, they get referred to an orthopedist or neurosurgeon, and 50% of back surgeries that follow are said to be unnecessary — turning a low-acuity problem into a high-acuity one

✅ Why the "triage before the triage" used to happen informally and no longer does: doctor's lounges, hospital rounding, and curbside consults between PCPs and specialists created spontaneous guidance pathways that have largely disappeared — and members are now left to self-triage with an answering machine that says "if this is an emergency, go to the emergency room"

✅ What Upswing Health does: members get access to an athletic trainer within 15 minutes and an orthopedic specialist within 24 hours — replicating the curbside consult dynamic at scale so members can be met in the white space and put on the right path before they self-select into the ER

WHY THIS MATTERS

The 2026 National Healthcare Expenditure data shows personal healthcare spending surging over 8% with no commensurate health dividend — people aren't getting significantly healthier, they are just getting more care, and not always the right care in the right setting. MSK is a concrete example of where that gap plays out in millions of plan dollars. It is not that members are making bad decisions — it is that they are being asked to make clinical judgment calls they are not equipped to make, with no one to call, at the worst possible moment.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP499

🔗  Visit Upswing Health: 
https://upswinghealth.com

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08:01 What is the "white space" in MSK spend?

10:43 Statistics on Connecticut's spending on plan members with low-acuity MSK injuries.

13:30 How back pain also easily transitions from a low-acuity issue to a high-acuity problem.

15:11 How plan sponsors can detect their white space downstream spend.

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18:15 Why where patients start their journey often dictates where they wind up and how costly that medical pathway is.

20:48 Where PCPs fit into this MSK spend issue.

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