High-Cost Care Is a Symptom, Not the Cause

Caroline Higgins, DPT, Sr. Director, Care Experience, Transcarent

Early in my career as an orthopedic and sports medicine physical therapist, I learned that pain is rarely the whole story. A person might have come in with knee pain, but the real issue was often somewhere else: the ankle, hip, back, or a movement pattern that created strain over time. Through the Gray Institute's functional movement approach, I learned to look for the root cause, not just point of pain. Employers face the same dynamic in healthcare. The pain shows up as rising spend, high-cost specialty episodes, surgery, and cancer care. But high costs are often the symptom, not the cause. The root cause usually shows up much earlier: people are not getting enough preventive care, lower-acuity support, guidance, or intervention. This can get worse when employers add disconnected point solutions that create fragmentation, resulting in duplicative costs, administrative drag, and confusing experiences.

The Case for Early Intervention

If employers address only the symptoms, they will stay stuck downstream paying high costs. Specialty care should not begin with a referral and always end with a procedure. It should start before a major intervention, stay active during treatment, and continue through recovery. Employers should engage earlier and guide people to more appropriate care before they end up on a more invasive and expensive path. Consider the data:

• Specialty care accounts for more than half of total healthcare spend, even though only a relatively small share of employees will need it in any given year.¹

• Cancer is now the number one driver of employer healthcare costs.²

• 15% of total medical costs are from musculoskeletal conditions, costing employers $300+ billion annually.^3,4

• 36% of musculoskeletal surgeries are considered unnecessary.³

Understanding the Cost of a Broken Journey

Too often, healthcare still operates on a handoff model: a person moves from one provider, program, or point solution to the next with little continuity, context, or accountability. This old model falls short.

When people do not know where to start, or understand next steps, the experience breaks down: more confusion, more unnecessary diagnostic testing or referrals, and more delay in getting to the right care plan. Employers then feel the economic consequences: reduced employee productivity, more downstream utilization, more avoidable procedures, poorer outcomes, and more spend tied to care that could have been redirected earlier.

Earlier Engagement Preserves Options

The future of specialty care starts upstream, before invasive treatment becomes the default. At Transcarent, the opportunity is not just to manage high-cost care better once it happens, but to improve Member experience and employer economics by helping people get the right care, at the right time, in the right setting. Success should be measured by avoiding unnecessary care, not by driving more volume through surgery.

For Members with MSK conditions, Transcarent helps avoid unnecessary surgeries through independent clinician review, nurse-led coordination, second opinions, conservative care pathways, and virtual physical therapy. With Transcarent, 23% of surgeries are avoided, and nearly 90% of those avoided cases remain surgery-free after 12 months.⁵ Members can get an orthopedic diagnosis and a personalized care plan within two days.

For Members at risk for or facing cancer, the opportunity starts even earlier—with stronger prevention, appropriate screening, and faster guidance when something feels off. Because cancer is now the number one driver of employer healthcare costs,² helping people catch concerns sooner and navigate next steps earlier can preserve options and reduce the need for more intensive, higher-cost care.

For me, that is the larger promise of specialty care done well. It is not just about delivering high-quality care once needs have become high-cost. It is about whether that intervention should happen in the first place, what alternatives were explored, how well the Member understands their options, and whether the system stays with them after care has been delivered.

One Connected Path, Not Disconnected Care

I believe this upstream, appropriateness-first approach to specialty care is the future. Members do not experience their health in silos. They want one trusted system that helps them get the right care at the right time, integrates their experience, and avoids unnecessary friction along the way.

This work feels personal to me. My career started with a simple goal: help people avoid unnecessary and invasive care, preserve function, and improve quality of life. That goal still motivates me.

The future of specialty care is not just better access to high-quality surgical care or cancer treatment. It is smarter upstream guidance, earlier intervention, stronger prevention, and making the complete care journey easier, from first concern to full recovery.

When we get that right, we do more than lower costs. We help people make better decisions, avoid unnecessary treatment and intervention, and feel supported in moments that matter most.

If you want to learn more about what a truly connected specialty care experience looks like in practice watch this on-demand webinar

References

1. Health Care Costs and Affordability.

2. 2026 Employer Health Care Strategy Survey, Business Group on Health.

3. From conference calls to construction sites: how musculoskeletal conditions impact workforce health.

4. Clinical and Economic Outcomes Associated With Musculoskeletal Care in an Integrated Advanced Primary Care Model.

5. Transcarent book of business