People with musculoskeletal (MSK) conditions have complex needs, high demands and often multiple co-morbidities, and they often require multiple pathways such as physical therapy, behavioral support, pain management etc. Most of them are not getting the optimal care.
The problem is widespread.
1 in 3 American adults suffer from MSK pain. 40% of patients are misdiagnosed every year and 50% of patients are back in the system with the same issue they were treated for.
This is not due to lack of investment.
MSK conditions account for 15-20% of annual health spend for employers. In the last decade, there has been 250% increase in surgeries, 400% increase in diagnostics and 500% increase in therapy. Musculoskeletal conditions dwarf other health conditions in health care spend, and also cause the highest out-of-pocket spending by members. Despite spending more money (in 2016, US spent an estimated $380 billion on musculoskeletal conditions), why are we still getting poor outcomes?
One key reason is that our existing healthcare infrastructure is built around doctors, facilities and insurance. It is not built around members and hence it is not able to cope with their multi-varied needs. That’s why members receive fragmented and poor experience. The highly medicalized and interventional system uses excessive diagnostics, treatments without clear evidence and with high cost and little outcome data. Many members receive surgical interventions, injections or dangerous drugs where conservative measures would have been far more appropriate.
The other reason is lack of ‘real’ accountability. While health systems strive hard to provide the quality care patients need, most of them don’t consider themselves accountable to the sponsors (self-employers) who are sponsoring the care for over 100 million Americans. Instead the care and administrative processes are designed around their relationship with insurance carriers, who are mostly acting as claim processors for the main sponsors.
The uncoordinated and inefficient care delivery system, supported by archaic insurance models means that employers and health plans have been spending far more on this than needed and receiving poor value for money, with high levels of waste (over 50%) in the system.
THE FRESH APPROACH
The right approach for the stated problem is the opposite of status quo. It is BOTH member-centric and sponsor-focused. It combines clinical expertise with innovative technology to offer members high quality care that provides them the best possible outcome.
This fresh benefits approach is centered around members, where the MSK benefits are based on a new service delivery model that creates a seamless experience for them and fits their already digitized lifestyle. In this delivery model, members choose where, when, and how often they want to engage and communicate about their issues with clinicians to get care.
The therapists, physiatrists, pain medicine and other clinicians are their expert health coaches, guides and conductors.
My guide should show me the right care pathway for my needs. My coach should tell me what I have to do and correct me when I am doing it wrong. My conductor should bring in other providers when I can benefit from them.
In this new MSK delivery model, the clinician come to the members—via video chat, messaging, and phone calls, communicates with them both synchronously and asynchronously about their symptoms and advises them on the best management for their condition.
This model enables a more holistic focus, encourages more conversation and provides the clinician with a better opportunity to ask questions and provide bespoke advice, education and reassurance, while also tackling some of the psychosocial aspects of pain.
In this delivery model, the remote monitoring technology provides data-based insights to clinicians, who can review the progress of their members on predicted trajectories of recovery.
The clinicians know when tasks have not been completed and provide timely and accurate feedback to improve their chances of a quick and safe recovery.
For members with chronic pain, this benefits approach provides evidence-based, clinically validated digital programs that includes the right interventions (physical, psychological, and educational) for maximum impact.
This multimodal approach combines physical and psychological therapies and is the most effective way to improve function and mood, and reduce disability for members suffering from chronic joint and back pain.
The new MSK service delivery model focuses on getting the diagnosis correct, and uses AI and clinical expertise for thoughtful screening and triage to evidence-based care in-app or in-person. The goal is to increase conservative care and drastically reduce referrals to secondary care.
It uses MSK assessment and triage to ensure that people with MSK problems are directed to the right treatment in the right place at the right time. It filters the referrals from primary to secondary care and takes a PT-first approach for MSK conditions because it provides a high degree of clinical diagnostic accuracy at 1/25th of the overall cost per MSK episode. Done properly, this can stop about 20% of the referrals and significant discomfort for members.
For members needing surgery, it provides care navigation and coordination through multiple modalities – online and telephonic – and services range from assistance in provider selection, to appointment scheduling, to support managing travel logistics.
This model also supports member’s needs after the surgery and provides post-surgical rehabilitation, that is convenient and effective. The therapist and member collaborate together to establish functional goals related to resuming normal activities of living as well as preventing an injury from recurring.
The therapist then designs an exercise program tailored specific to the member’s needs and abilities, and work. Unlike traditional clinic-based therapy models, where adherence to home exercise in rehabilitation is a significant problem (with estimates of non-adherence as high as 70%, having a detrimental effect on clinical outcomes), this model tracks member adherence to exercise plans and report it back to the therapist for course-correction, when needed.
The modern approach requires MSK providers to be focused on sponsors’ needs (vs. claim processors) and provide them a service delivery model, that is comprehensive, integrated, digital-first, easy-to-implement and accountable..
Ideally this is not speciality-centric (PT, Chiro, ortho etc.), nor is it a point solution for acute or chronic. Instead in this approach, the care provider meets the unique needs of members at every stage of their care journey – from preventive to post-surgical rehab.
Having one integrated health platform for MSK care obviates the need of integrating the disparate, disintegrated solutions such as Tele-PT, digital therapeutics, care navigation, COE etc. that not only are resulting in confusion and clutter for their members, but also does not provide the quantifiable metrics on overall cost of care and health outcomes.
A digital-first, enterprise-scale, integrated approach to MSK care means that everyone in your employee population with any MSK condition, at any stage of their journey – receives a fast, easy, consistent approach to care, with a single point of access to services.
This comprehensive approach to musculoskeletal (MSK) benefits also provides evidence-based, systematized pathways to members wherever they are in the musculoskeletal care continuum.
It creates a seamless experience for all of their needs including but not limited to finding therapists, doctors, facilities or imaging centers, accessing their health records, accessing benefits, scheduling appointments, virtual visits, e-triage, visit follow-ups, treatment plans and asynchronous messaging to stay connected with their providers and care team.
This approach requires the health platform to be Digital-first, which means that it focuses on optimizing care utilization process by using digital services as an anchor that improves quality and cost outcomes in the entire care delivery system. However it is not digital-only because for some members in-person therapy or treatment is the best option. In such cases, this model coordinates the care across specialities, settings across the continuum.
In this model, the solution is easy-to-implement and it works nicely with other products and partners in the benefits ecosystem by sharing data and collaborating with them for the best of members. It tailors a year-long engagement plan to sponsors’ needs, including benefit design, wellness events, customized communications, and outcomes reporting.
By combining claims and other sources of data, it uncovers high-quality, low- cost providers with the best outcomes and uses that information to steer employees and their family members away from low-value treatments and overpriced healthcare providers through benefit design incentives – providing significant savings.
The model drives quantified quality, experience and financial measures, as compared to sketchy and basic measures of physical encounters reported via claims today.
As pressure grows to get better value from healthcare investments and reduce overall cost—especially in light of changing macroeconomic conditions—employers and health plans should push for health platforms that take a fresh approach to care. Sprite Health’s digital MSK HUB 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.