Challenge

Musculoskeletal care delivery in United States is highly fragmented. People with a musculoskeletal problem may go to primary care physician, or get referred to a specialist but there is a spectrum to choose from, such as rheumatologists, orthopedic surgeons, physical medicine and rehabilitation (physiatrist), sports physicians or other health professionals such as physical therapists, chiropractors or osteopaths. We would assume that all specialities should have a similar expertise in assessment and general management of musculoskeletal (MSK) problems, and may  differ only by the types of interventions, that is not the case. In fact, there is little commonality between these provides in diagnosis and assessment.

In addition, no area of clinical over-treatment is as egregious as musculoskeletal (MSK) care. For example, Only 1-5% of people with back pain have a problem that requires urgent treatment, yet 40-60% of people with back pain are sent for scanning – leading to massive waste.

U.S. surgical rates compared with other similar countries suggests that 50% of all orthopedic and spinal procedures are simply unnecessary.

Employees and dependents continue to go to specialists and ER for musculoskeletal services which can be more cost effectively treated by physical therapy. For example,  over 13 million Americans see their doctor each year for relief from chronic low back pain. The right physical therapy within 14 days of the onset of pain minimizes the average total cost of care by 50%. Low back pain patients who receive physical therapy immediately after the pain begins and adhere to their treatment plan spend $3,000 a year in associated healthcare costs. Those who delay receiving physical therapy and do not adhere to their treatment plan spend $6,000 per year for all kinds of healthcare. 

Opportunity

This challenge provides an opportunity to the employer and health plans to re-define musculoskeletal care benefit based on predictable costs and specific outcomes.  A design where easily accessible, low-intensity  longitudinal care is provided by physical therapists in a lower cost, high-value digital care setting.

Model

This benefit can be delivered in a “carve out” model by direct partnership between employer & a provider of digital musculoskeletal pain management or “included” in the broader plan contracted with a health plan, an ACO or an integrated health system.

Services

Generally speaking, digital physical therapy services can be grouped into the following categories –

  • Initial Evaluation and Treatment Plan
  • Physical therapy sessions
  • Home exercises
  • Remote monitoring and support

Any services that lands outside of the core services should be closely overseen by the designated physical therapist.

Plan Goals

Besides getting member back to function, the plan goals should specifically include:

  • Reduction in total claim costs for employees and dependents.
  • Significant reduction in ER and outpatient claims.
  • Metrics to measure outcome measures such as pain reduction, improvement in function, self-efficacy, impact on distress etc.

Plan Design

For musculoskeletal care, VBID (value-based insurance design) can be an innovative solution to maximizing health outcomes with available health care budget.  The basic premise of VBID is to align consumer incentives and payment strategies with value by reducing barriers to high-value health services.

For example, you can choose to eliminate copays for physical therapy evaluation and treatment. This will help members to access physical therapy early and help you reduce expensive downstream surgeries and injections.

Any additional costs for such incentives can be balanced by raising co-pays and/or co-insurance for using “unnecessary” ER visits for normal MSK issues.

Payment Model

Services in this model should be paid for through subscriptions. Employees should enroll in the MSK home, and care providers can be paid a risk-adjusted amount per enrolled member per month. The risk adjusted score can be based on a mutually agreed methodology for determine low, moderate and high risk members.

Low Risk: Healthy members with very limited need of care.

Moderate Risk: Members with one or more chronic musculoskeletal condition.

High Risk: Members with multiple chronic musculoskeletal conditios, and who are accessing healthcare regularly.

Provider Incentives

To better align care providers, you may choose to add incentives (based on health outcomes and other metrics) on top of the subscription costs.

Plan Metrics

Since the goals of the new model is to improve general MSK health, redirect care to physical therapy first, manage chronic pain management and manage referrals, metrics should include-

  • Reduction in PMPM costs for specialist, ER and Outpatient care.
  • Reduction in overall claim costs.
  • Improvement in health outcomes based on conditions managed in care plans. For example, how average drop in pain levels for all members enrolled in chronic pain management programs.
  • Number of referrals managed.
  • Member engagement in their care plans.
  • # of same day/next day appointments

Talk to us about how Sprite Health can reduce MSK costs, improve health outcomes and provide you better visibility &  control over your musculoskeletal benefits.

Sprite Health’s corporate musculoskeletal program provides a single point of access for all MSK conditions, across the entire MSK continuum. Our virtual physical therapy services provide a more affordable and convenient way to prevent and treat pain. Chronic pain management provides an evidence-based, PT-led digital program for chronic joint and back pain that includes personalized exercise therapy, behavioral health support, education & guidance. Bundled surgery provides access to high-quality musculoskeletal surgical care at a pre-negotiated bundled rate. MSK financial management leverages predictive analytics, clinical expertise and plan administration capabilities to eliminate waste – resulting in over 30% net savings in your MSK spend.

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1 comment

  1. It’s good to learn that primary care has to include preventive care and routine visits. My brother is wanting to start a primary care firm and he was wondering how he could make his business one of the best in the city. I’ll be sure to tell him to not forget about preventative care and routine visits with primary care.

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