Why MSK is your biggest claims cost — and what to do about it

Musculoskeletal conditions are the single largest driver of claims costs for most Australian private health funds. And yet, by the time those costs hit the books, it's usually too late to change what happens next.

That's the problem. Not that MSK is expensive – it's that it becomes expensive in the dark.

The size of the MSK burden you're already carrying

Around 1 in 3 Australian adults live with a chronic musculoskeletal condition, according to the Australian Institute of Health and Welfare (AIHW). That's roughly 4.5 million people – many of them your members.

The total cost to the Australian economy sits at an estimated $53 billion per year. That figure includes hospitalisation, surgery, allied health, and the downstream costs of reduced workforce participation.

For health funds, the impact lands in a few specific places: orthopaedic admissions, physiotherapy extras claims, imaging, and – increasingly – mental health support for members whose pain has dragged on long enough to affect their quality of life.

The challenge isn't that MSK is complicated. It's that the current system is designed to respond rather than prevent.

Why the cost shows up late

Most health fund members with joint pain don't come to you until they're already in trouble.

They've often been living with discomfort for months, managing it with anti-inflammatories or simply resting more. By the time they book a GP appointment, get a referral, wait for a specialist, and are eventually assessed for surgery, a significant opportunity for early intervention has passed.

This is the core problem. MSK cost often shows up late – after function has dropped and care has escalated. At that point, the options are fewer and the price is higher.

Three things make this worse for health funds specifically:

Limited visibility upstream. You can see claims. You can't easily see members who are quietly deteriorating before they lodge anything.

Fragmented pathways. A member might see a GP, a physio, a specialist, and an exercise physiologist – with no single thread connecting them. Every handoff is a drop-off point.

High-cost end-stage care. Hip and knee replacements are among the most common and expensive elective procedures in Australia. Once a member is on that path, the question isn't whether to fund it – it's how to make sure they get the best result.

What early intervention actually looks like in practice

Early intervention in MSK isn't a new idea. The challenge has always been operationalising it at scale – connecting the right member to the right support before the situation escalates.

The evidence increasingly points to hybrid models: structured digital programs combined with qualified physiotherapist support delivered via telehealth. This approach gives members access to care that fits around their life, while maintaining the clinical rigour that actually changes outcomes.

In Beyond The Clinic's Project Mobilise pilot – a real-world, six-week program delivered across private health, community, and surgical settings – early results were encouraging.

Pilot data showed that 60% of participants saw meaningful improvement in pain, and 71% increased their daily step count, with an average increase of 2,242 steps per day. Among participants who activated the program, retention was strong: only 4% opted out once they had commenced.

These aren't people in a controlled research environment. They're the same profile you'd expect in a general member cohort – average age 58, average BMI 30.6, average baseline pain of 4.7 out of 10.

The model works because it combines two things that are usually separated: the structure and convenience of an app-based program, and the accountability of real clinician support.

The cost case for acting upstream

For health funds, the financial case for upstream intervention rests on a few straightforward assumptions.

If a member with mild-to-moderate knee pain is identified early and supported through a structured program, a meaningful proportion will avoid or delay the need for surgical management. Even a modest reduction in elective orthopaedic admissions – across a large member base – represents significant claims savings.

Beyond surgery, there's the extras cost picture. Members who engage with effective conservative care early tend to need fewer ad hoc physiotherapy claims over time. They're managing a condition, not chasing symptom relief.

There's also the member experience dimension. Health funds that offer proactive, personalised support for MSK tend to see stronger member retention and satisfaction – particularly as members age into the higher-utilisation years.

The question isn't whether upstream intervention is worth funding. It's whether the model you're funding actually delivers.

What a scalable MSK program needs to do

Not all digital health programs are created equal. For a program to work for a health fund, it needs to do a few specific things:

It needs to identify risk early – before claims escalate. That means a validated screening tool that can triage members into appropriate pathways based on their actual clinical profile.

It needs to be engaging enough that members stick with it. The biggest problem with digital health programs is drop-off. A hybrid model that pairs technology with human support performs significantly better on retention than digital-only approaches.

It needs to produce measurable outcomes – not just engagement metrics. Retention rates are useful. Pain scores, function measures, and step counts are better. Reduction in surgical referrals is the goal.

And it needs to integrate into your existing referral and care pathways without creating administrative burden for your team or the clinicians you work with.

That's the model Beyond The Clinic is building for health fund partners. It starts with the Joint Health Profile – a validated screening tool that identifies MSK risk and matches members to the right level of support. From there, the JointFit program delivers structured care via app and telehealth, with real-time data available to your team.

The conversation worth having

Australian health funds are increasingly focused on value-based care – funding what works, not just what's billed.

MSK is one of the clearest opportunities to put that into practice. The conditions are common, the costs are predictable, and the evidence for early intervention is growing.

The challenge is finding a partner who can deliver at scale, with clinical credibility and outcomes data to back it up.

If that's a conversation you're ready to have, we'd welcome the chance to walk you through the model.