The musculoskeletal landscape in America is expansive and expensive. It is expansive because 50% of American adults are experiencing a musculoskeletal condition. It is expensive because it is now estimated to cost about a $1 trillion.

Who is paying for it?

Both employers and their people.

For over 150 million working Americans (under-65), employers are paying more for MSK than anything else in healthcare including cancer, cardiovascular, T2 diabetes.

It’s not just the employers, this ever-increase cost-burden is shared by their employees too. Not only do musculoskeletal conditions dwarf other health conditions in health care spend, they also cause the highest out-of-pocket spending by members.

Where is this money going?

Not in the right pockets.

82% of this spend is on surgery, imaging and drugs. When employees are experiencing pain and aren’t getting the right help they need, some are likely to opt for expensive and occasionally unnecessary surgeries. Unnecessary because 40% of patients with MSK conditions are misdiagnosed.

Unfortunately, choosing surgery over other conservative treatments does not work well for many of them and 50% of patients are back in the system within 12 months of treatment with the same issue.

Where should we start when we have a non-emergent MSK issue?

Dr. Google and transparency tools are not the right place to start searching for right treatment for MSK conditions. People with MSK conditions have complex needs and when they are seeking help, they often find multiple musculoskeletal care options that are unclear and confusing. Given the high rate of misdiagnosis and recurrence rate, this problem is not solved with transparency tools as well. Where you start often determine the health and cost outcomes and while getting upfront pricing is helpful, but does not address this issue.

Is PT the right place to start?

Yes, for 90% of MSK conditions. For part of the remaining 10%, PTs can provide the assessment, help and advice to pick the right treatment at the right time. However getting the diagnosis right is the first priority.

To find the answer for clinical diagnostic accuracy, in absence of a broad known research, we looked at a previous research paper on what specialities score well on finding the right diagnosis. This research has some limitations (focused on MRI in collaborative setting), but gives a good idea on the clinical diagnostic accuracy by PTs and orthopedic surgeons on patients with MSK injuries. Both speciality types had significantly greater accuracy than that of non–orthopedic providers.

Who is more accessible?

Physical therapists.

Typically, members are seen within 2-3 days of scheduling an appointment, while it takes an average of 2-3 weeks to see a primary care physician or orthopedic surgeon. 

What treatment pathway is more expensive?

The answer is relatively simple. Accordingly to several published reports, the cost-differential between choosing the right provider type (PT for over 90% of MSK issues) vs. orthopedics is over 25 times in the whole MSK ‘episode’.

In other words, with PT-first, we are likely to get a high degree of clinical diagnostic accuracy at 1/25th of the overall cost per MSK episode. It seems plausible that physical therapy may be the best first line of defense against musculoskeletal pain. No wonder PT is now recommended by the CDC as the preferred first treatment for chronic pain and an effective alternative to opioids and surgery in many cases—and the research supporting this recommendation continues to mount.

Despite the clinical practice guidelines, the current US healthcare system often fails to successfully engage patients and their providers in adherence to those guidelines. In 2019 study of 2.5 million patients with back pain, 38.7% of surgically treated patients did not receive any conservative care prior to surgical intervention as recommended by multiple treatment guidelines.

What happens if you start on the wrong foot?

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Patients who receive low-value, inappropriate care for chronic pain experience worse outcomes than patients who receive conservative, higher-value measures such as PT.

Low-value care is particularly pernicious for LBP patients, as low-value interventions, such as imaging, may lead to further low-value care, such as surgery, with the accompanying potential for negative outcomes or side effects. Likewise, the use of low-value care such as opioids instead of higher-value care, such as PT, may cause the patient to transition from acute pain to chronic pain and may lead to opioid use disorder.

Makes sense, so why don’t members choose PT as first-line treatment for MSK?

If PT-first approach can do better diagnosis, lowers opioid use and reduce unnecessary surgeries and imaging (which makes up 82% of the overall spend), why is it not encouraged by plans?

This is because member’s choice of first-line treatment is influenced by health insurance cost-sharing features. At the point of new symptom onset, member preference for provider type is strongly influenced by out-of-pocket (OOP) costs, which may be higher for members who choose conservative therapy that involves repeated visits to a physical therapist or chiropractor. In the case of co-payments, there are variation within plans across provider types. Hence, it is possible that financial barriers deter members from seeking early conservative therapy despite its high value relative to other available treatment options.

Why is cost-sharing for Physical therapy different than primary care?

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Health plans and employers often classify physical therapy services as “specialty care.” This presents two main concerns. First, as mentioned above, members are discouraged from seeking services—especially when multiple visits are needed, as is often the case—because their portion of the cost is too burdensome. Second, the AV (actuarial value) for PT is often 60% or less – meaning that insurers/sponsors pay about 60% of the reimbursement rates for the service, almost the same as the members, leaving the actual physical therapy “benefit” as minimal. In contrast, it often 80% to 90% AV for seeing PCPs or Cardiologists.

Is cost-sharing differential based on actual cost of care?

PT is not expensive on a per unit basis. To members, physical therapy costs from $20 to $150 per session on average depending on the extent of their injury, phase (pre-deductible or post-deductible) and if they have insurance coverage. With insurance, rates range from a $20 to $55 co-pay after they’ve paid their deductible, and between $75 to $150 if they’re paying without insurance.

It is not cheap on a per-episode basis, though. According to The American Physical Therapy Association (APTA), physical therapy for chronic or lower back pain costs $126 per session with most spending between $1,000 and $1,260 for around 8 to 10 sessions of treatment over six weeks.

Relatively speaking, it is not bad. At 80% AV on an average, the total cost for the average episode of care, or 10 visits, comes to about $1,000. Still much more cost effective than the alternate options.

What is the right copayment for PT?

Somewhere between $0 and $20

The odds of seeing a physical therapist as first provider decline steadily as co-payment increases.

The patients with a co-payment of greater than $30 are 29% less likely to see a physical therapist first than patients whose co-payment is zero.

VBID and TRICARE experiment

TRICARE, the health insurance system used throughout the U.S. military, is set to launch a pilot project that waives cost-sharing for up to three physical therapy visits for patients with low back pain. This concept is based on Value-Based Insurance Design (V-BID) principles, which recommends lowering or removing financial barriers to essential, high-value clinical services and aligning patients’ out-of-pocket costs, such as copayments and deductibles, with the value of services.

Pushing Toward Value-Based Health Insurance Coverage

TRICARE found out in their research that that rates of attendance to at least one physical therapy session varied significantly, ranging from active duty beneficiaries at a 65% attendance rate to non-active duty dependents only reaching 38% attendance. The low-attending group happens to have the highest cost-sharing requirements for physical therapy. The experiment of cost-sharing waivers is based on an assumption that it could help to increase participation in “high value” treatment for LBP.

Should self-funded employers follow?

Cook et al have demonstrated that patients reporting at least 50% reduction in pain in the first 2 weeks of a PT plan of care have a significantly greater likelihood of reduced disability at 6 months. This means that if PT is found to be the ‘right’ treatment for a member in the first two weeks, there is a strong chance of better outcomes at lower costs. This argument supports waiving cost-sharing for first 3 visits or first 2 weeks.

However PT is often associated with lack of clarity and over-utilization. Often  ‘two visits a week for four weeks’, does not describe what is to be done during those visits, who’s supposed to do what gets done, and equally important, what shouldn’t be done.

Also, more physical therapy visits don’t necessarily equate to better treatment. The right model appears be a combination of PT-led care delivered at home.

With MSK conditions, it helps if you see a physical therapist first, who can do an evaluation and tell you what muscles are weak or tight, can design a personal exercise program and can teach you the exercises. You follow the instructions at home or gym, and then return to physical therapy in a few weeks to check on your progress.

What about virtual physical therapy?

Much more so than with traditional care, virtual physical therapy includes a larger educational component. Because the therapist is not physically present to assist with movements or joint stabilization, the onus is much more on the patient to learn these techniques and practice them continually.

Self-management is a big factor. But that can translate into faster recovery. Instead of a patient practicing these movements three times a week with their therapist, they are encouraged and enabled to do them three times a day on their own.

Evidence-based MSK benefit design based on quantitative measures

Beyond using historical claims and trends for determining coverage and cost-sharing, employers and health plans should also look at disease burden in their member population and use evidence-based frameworks that leverage quantitative measures. For example, does incentivizing the use of PT services reduce the total cost of care for a MSK episode, or reduce the number of opioids prescribed? Does waiving cost-sharing for up to three PT visits increase the initial uptake of PT visits among patients with MSK conditions?

Let’s recap

  1. MSK conditions affect 1 in 2 people and are very expensive to treat.
  2. Employers and health plans are getting poor value for their MSK investments because 82% of their money is spent on non-conservative care.
  3. PT provides high degree of clinical diagnostic accuracy, is suitable for over 90% of the MSK issues.
  4. PTs are more accessible than alternate options and cost significantly less (per session level as well as at the episode level)
  5. The right physical therapy within 14 days of the onset of low back pain minimizes the average total episodic cost of care by 50%.
  6. The current cost-sharing model for PT in most health plans is not aligned with the value it provides.
  7. $0-$20 appears to be the right copayment for a PT session.
  8. Employers and health plans can also explore waiving first 3 sessions or two weeks of therapy, to determine if PT is the right fit or triage if it is not.
  9. To avoid over-utilization, PT-led care delivered at home appears to be an optimal combination.
  10. Telehealth physical therapy is here to stay. It includes a large educational component, and can be integrated into the fabric of people’s already digitized lives.

Talk to us about how our digital musculoskeletal platform can help you with Virtual Physical Therapy, MSK Triage, Chronic MSK Care and MSK financial management to reduce your musculoskeletal spend by over 30%, reduce dangerous drugs and unnecessary surgeries, and improve health outcomes for your people.