The impact of COVID-19 on employee benefits can’t be understated. The service utilization patterns are significantly changing as people continue to evade elective procedures, as well as essential preventive and primary care. There’s no blueprint for what we’re facing and benefit leaders need to change strategies to keep up.

What we know for sure is –

a) More companies continue to embrace remote working and with employees doing their jobs from the couch or at the kitchen table, a major downside has emerged: new or worsening back, neck, leg, and shoulder pain.

b) Employees’ preferences for care access have evolved, and use of telehealth has skyrocketed. Virtual visits may become our new normal.

With Telehealth getting over the tipping point into widespread adoption, the employee population is likely to demand a digital MSK solution to address musculoskeletal conditions such as back pain, from the safety of their home. Some employers have already started to explore point solutions in remote physical therapy, digital therapeutics for chronic pain, virtual rehab etc. While a thriving ecosystem of musculoskeletal (MSK) point applications looks like a great thing, for many companies it is quickly becoming a source of aggravation. Benefit leaders are concerned about efficacy of these solutions, as well as administrative and technical challenges in vendor management.

Before you expose your employees to an uncoordinated onslaught of user interfaces, logins and communications, it is important to understand what makes an effective solution for one of the largest cost category in your health spend. Here is our take –

  1. Easy and quick access to right care anytime, anywhere

An effective digital MSK solution should makes it easy for your people to quickly get the right care. It may be for a minor ankle sprain, an acute injury, chronic pain, a rehab or anything else.

We know that some people prefer to use messaging and some others like a live video session. The system should allow for multiple modes of treatment – asynchronous messaging, telephone, video as well as coordinate in-person care, when needed.

Besides initiation evaluation and follow-up scheduled sessions, a good system enables members to go back-and-forth and communicate with the therapist anytime between sessions. This is very useful in a scenario where a member can use messaging for getting a better understanding of how a certain exercise should be done.

For complex problems, the digital MSK system should provide access to MSK specialists who can perform detailed assessments for precision diagnosis and triage members to the right evidence-based care, in-person or in-app. In such cases, a modern enterprise-grade MSK solution takes a project management approach where member and her care team come together with frequent messaging for minor issues and scheduled sessions for big actions. The information collected during these interactive sessions is available to the entire care team as well as the member – anytime, anywhere.

2. Integrated

The MSK landscape is both wide and deep. It goes across multiple conditions and each condition has multiple stages of progression. The complexity is much higher if there are comorbidities, often the case in chronic MSK pain.

People with musculoskeletal conditions encounter a care delivery system that is fragmented across specialities, treatments and facilities. Even within the digital MSK solutions marketplace, while there are several evolving point solutions for therapy, chronic pain, rehab etc., most of them exist in vacuum and don’t integrate with other applications in the employer’s benefits ecosystem. This is challenging for employers and health plans, who now have to find a way to glue these apps to create consistent experience for their people as they transition from one stage to another. It is also cumbersome for members to have to know five different logins for different apps.

An effective digital MSK care system is integrated. It provides a single point of access for all musculoskeletal conditions, and coverage across the continuum, from preventive to postoperative rehab.

It incorporates evidence-based care pathways for acute, chronic, triage, pain management, surgery and rehab. These pathways define predictable course for a specific condition and state, in which the different tasks or interventions by the care team (as well as the member) are defined, optimized and sequenced.

3. Shared decision making

Shared decision-making (SDM) is the practice of engaging members to ensure that a member’s treatment option is right for her. It is based on the thought that healthcare professionals are the experts on the medical evidence and members are the experts on what matters most to them.

Shared decision making is the fundamental tenet of an effective care model. It encourages ‘why’ and ‘what are my options’ for members.

When members are involved in decisions about their health, they are more invested in their treatment, which results in better outcomes. Yet most members don’t receive a simple answer for their issues that outlines all the treatment options with clear explanation of costs.

An effective digital MSK pain management solution puts member in the middle of her own care. It takes into account what factors matter most to the member, her preferences, values, attitude to risk, social circumstances and gives the member stake in her treatment.

An example of shared decision making is an interaction between independent clinicians and members before major surgery (such as total hip and total knee replacement). The clinicians enable members to understand the risk of surgery, ensure that all conservative measures have been optimized, and they need and want surgery, are prepared for it and surgery will help them achieve their goals.

4. Evidence-based multimodal care

Somatic experiences of pain often leads to psychological distress and strain in employees. Employees living with chronic pain have a higher risk of developing depression. Research suggests that anywhere from 30 to 50% of people with chronic pain also struggle with depression or anxiety.

An effective MSK solution is multimodal. It blends technology, physical therapy (PT) and behavioral support to address the complex nature of chronic MSK pain. If PT and behavioral health are combined in a structured program, they greatly complement each other. For dealing with a chronically aching back or general soreness, stiffness and pain, movement is the best course of action. That’s where physical therapy comes in. Guided and paced physical activity has the capacity to retrain the brain and therefore chronic pain.

Behavioral health support helps people cope with the thoughts, feelings and behaviors that accompany chronic pain. By shifting patients thinking away from the pain and change their focus to more positive aspects of their life, they can change the way their body responds to the anticipated pain and stress.

5. Clinical and Financial

Most point solutions in the MSK marketplace claim to save costs. Yet even after these solutions are deployed, the employers don’t see any change in their MSK spend. Why is that?

Even though MSK conditions are pervasive and impact 1 in 2 workers in any given year, majority of the spend is concentrated around a smaller cohort of people. Surgery, imaging and associated drugs make up 82% of the spend, and that spend is limited to small % of people who utilize these services. There is also persistent utilizers in MSK – 4%-5% of people contribute to estimated 35%-40% of spend when measured over two year period. Unfortunately these people don’t enroll (nor are they encouraged to enroll) into standard digital therapeutic MSK programs.

The membership profile of most MSK point solutions is a self-selecting, low cost, low risk group which is often motivated to get better. Majority of these people experience minor pain, which can be addressed with simple exercises.

An effective digital MSK solution covers the entire population impacted by MSK conditions, across the continuum. From low risk – low cost to high risk-high cost.

When choosing a treatment option for non-emergent elective treatments, members weigh it against both clinical and financial impact. An effective digital MSK solution combines both elements. The treatment options presented to the members not only include the clinical effectiveness but also clear, upfront costs, in advance.

Most employers are not able to 100% subsidize all MSK care for all members, in that case the MSK system provides flexibility to define cost-sharing options based on the effectiveness or value of each treatment pathway.

The system uses risk stratification tools to understand the clinical and financial risk in the entire member population by leveraging multiple data feeds for risk and utilization indicators. When measuring and reporting outcomes, it reports both financial and clinical outcomes per risk category.

6. Digital-first, but not digital-only

Delivering virtual care during this pandemic is more important than it has ever been. Consumer expectations are changing as more people have been introduced to virtual care services. While there are some very good use cases where much of the care given in low acuity cases, as well as chronic pain can be transitioned effectively to a digital medium; majority of the care for members with complex MSK issues has been and should be performed in the in-person settings. An effective digital MSK solution does not leave these people out to figure things out on their own. It facilitates and coordinates in-person care for them, as needed.

Digital-First strategy focuses on optimizing care utilization process by using digital services as an anchor that improves quality and cost outcomes in the entire musculoskeletal continuum of care, in-app or in-person. In contrast, Digital-only options leave out the people who can be more effectively treated in a hybrid (digital and in-person) or in-person setting. That does not work for many employers, especially if you have older people in the population mix. The hybrid model requires careful consideration of which clinical circumstances should command in-person attention and which cases can be handled just as effectively — and perhaps more conveniently — with a virtual visit.

An effective digital MSK solution is member-centric and not fixated on technology. It creates a seamless experience for the members irrespective of the care setting, with easy transition from digital to in-person and back, from one speciality to another, from one pathway to another.

7. Engaging

It is well known that members who are more actively involved in their health care experience better health outcomes and incur lower costs. Given that musculoskeletal (MSK) care is typically provided in multiple sessions, it takes consistency and commitment by members with their repeated completion of exercises to reduce pain and improve function. This consistency over a long period of time is difficult to achieve in the traditional model of care delivery.

An effective Digital MSK solution incorporates a modern user experience built on personalization, interactivity, convenience and easy access.

It enables proactive engagement of members to stay compliant with their treatment plan. Not only does it include high-quality musculoskeletal care from experienced clinicians, it meets members where they are in their continuum of care. It motivates members and help them manage their health on their own the vast majority of the time, making decisions daily that improve their health. It provides for a friction-free, frequent interaction between members and their care team to foster a sustained relationship to enable timely interventions, encourage communication, and promote self-management.

8. Goals and daily checklists

Given the information asymmetry during therapy sessions that favors the therapist, members forget 40%–80% of the information given when they walk out of their therapy sessions. Besides that, almost half of the information is not remembered correctly. An effective digital MSK solution enables therapists to provide information in clear, simple language and in an easily digestible form. This includes instructional videos for exercises, educational content or behavior therapy assessments.

Setting goals is the best way to achieve a successful outcome. The solution should allow personalization of goals set through shared decision making. It should track long-term goals – what a member will be able to achieve at the end of the treatment, as well as short-term goals that will help achieving long-term goals.

The effective digital MSK system enables clinicians to define goals at weekly/bi-weekly levels and prescribe exercises, diet plans, education materials to make it happen. Instead of email or paper, the solution helps members to stay on track by receiving their personalized programs directly to their web and mobile apps as a daily checklist.

A journey of a thousand miles begins with a single step. Achieving short-term success, one step at a time motivates members to stay on the course of recovery.

9. Frequent monitoring and feedback

Latest research have shown that frequent monitoring and feedback improves members’ adherence to their care plans.

An effective digital MSK solution enables both self-monitoring as well as remote monitoring by therapists. Members want a clear idea of where they are in the care plan and how well they are progressing against the goals. The solution enables the members to track sets and reps, keeps them engaged in doing their exercises and in reporting their progress. Frequent monitoring enables them to take true ownership of their condition and collaborate with their care team in revising these plans to achieve better outcomes. A study by Cleveland Clinic showed that allowing patients to record and monitor data specific to their care programs helped to improve patient engagement significantly.

Engagement is not one-way street and besides monitoring, member’s feedback is one of the key driver.

An effective Digital MSK solution enables timely feedback by members to their care team that provides insights into their progress and indicates if an exercise program should be changed. Regular data exchange can help to optimize treatment plans over time. It also creates another touch point between member and her therapist, reinforces encouragement and can thus help to build a stronger relationship.

10. Outcomes driven quality measures

Most point solutions define outcomes in simple terms – pain and function. While these are good metrics for clinical outcomes, they don’t often provide the full picture on the effectiveness of the solution.

An effective digital MSK solution provides a complete story – one that includes clinical, process and financial measures.

Clinical measures include patient-reported outcome such as pain intensity, as well as secondary clinical outcomes specific to the body-site (for example KOOS for knee pain, SPADI for shoulder pain).

The process measures includes the impact of cost-sharing on the utilization – reduction in opioids, imaging services, surgeries as well as reduction of total cost of care per episode. These measures also check if improving access to digital services impact the prevalence of chronic pain in the population, or reduce the number of low value services.

In addition to the above outcome measures, the digital MSK solution should include member surveys to measure reasons a member begins and ceases a pathway, as well as access to care, quality of care, and overall health status.

11. Reporting and analytics

In addition to outcomes measures, an affective digital MSK solution must include easy-to-use reporting and analytics to provide benefit leaders the information that they need to make informed data-driven decisions. The right system routinely checks data against key quality measures, identify gaps in care and generate appropriate alerts for members, caregivers and administrators.

To achieve the goal of putting the right information in front of the right people, at the right time, the solution must be able to do the following –

  • gather claims data from multiple sources, and transforming this data into a usable format.
  • apply analytics to the data – metrics, reports, trends, graphs, work lists.
  • manage the care for the defined population – work lists for care managers, alerts and reminders for therapists, notifications and reminders to members

The information gathered from comprehensive reporting and analytics provides an overall picture of the risk, incidence, prevalence and trends of musculoskeletal conditions to compare and benchmark across other employers as well as providers.

12. Flexible benefits and Incentives design

Instead of one-size-fits-all approach to benefit design, an effective digital MSK solution provides maximum flexibility in experimenting with benefit designs, for example, waiving co-pays and co-insurance for high-value services such as virtual physical therapy.

The VBID (value-based insurance design) approach seeks to achieve improvements in health outcomes through financial incentives in benefits design – mainly by reductions in cost-sharing to reduce barriers for targeted population in accessing high-value services.

VBID is clinically nuanced, meaning that the solution should consciously identify treatments and services most likely to improve health and change benefit design to influence use of those services. By aligning employee’s out-of-pocket costs with the value, the utilization of services with proven value is likely to go up and vice-versa. This can have a significant impact on reducing the waste.

In addition to benefit design, the solution must have a user experience that brings together the latest advancements in design, social theory and game mechanics to design rewards and incentive programs that encourage members to take steps towards improving their health.

13. Value-based payments

Many studies have shown that prices for MSK treatments are dramatically different not only across geographies, but they vary substantially even within the same market for the same service. Further, there is less evidence suggesting that higher-cost treatments are also higher-quality. Over 82% of musculoskeletal (MSK) spend is on imaging, surgery and drugs. These are also the categories where we see a high degree of variation in pricing.

Instead of focusing on better ‘discounts’ in fee-for-service model, forward-looking companies like Boeing, Walmart, Intel, GM are shifting to alternative care and payment models focused on value. This innovative model compensate providers based on outcomes and not cost & activities.

An effective digital MSK solution facilitates and administers value-based payments. It utilizes machine learning to assess which value based payment models best meet the employer’s budget and address the quality and cost expectations. The solution enables employers to pick and choose the right ‘Pay for Value’ payment models (Bundled, Shared Savings, Shared Risks, Capitated) that works best for their benefit strategy.

14. Waste elimination

Employers spend 15% -20% of their annual health spend on MSK conditions and 50% of that spend is wasted.

Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516. 10

80% of the waste is recoverable. An effective digital MSK solution is built on an analytical platform that eliminates waste, inefficiencies and excess  costs by addressing inappropriate utilization & price variability. The waste analysis provides various models for cost-saving opportunities. Risk segmentation helps identify the  targeted interventions that maintain good care and help avoid the cost increase.  Form, discipline, and structure to plan administration processes reduce the administrative waste.

15. Easy to deploy and integrate

An effective digital MSK solution is easy to deploy. It provides employers to choose a bundled or a-la-carte model. Bundled model includes end-to-end clinical care for all MSK conditions, as well as financial management to eliminate waste. The a-la-carte model helps employers to mix and match solutions based on their benefits strategy and the unique needs of their population.

Both models should be easy to implement. The solution should include all the heavy lifting, from on-boarding to engagement to reporting, and more. It should tailor a year-long engagement plan to meet employers’ needs, including benefit design, wellness events, customized communications, and outcomes reporting.

The solution should fit well with other benefits in the ecosystem by providing secure access to its APIs, as well as data exports into broader analytical tools.

SUMMARY

Despite the impact on employee wellbeing during this pandemic, one thing is constant: US employers will continue to invest in the best healthcare benefits for their people. A digital MSK solution holds the promise of getting better musculoskeletal health outcomes for employee population and reducing medical costs. This is no longer just an idea. To provide relevant benefits that fit the new lifestyle of their people, employers should consider this in their future plan designs.

Sprite health helps employers and health plans get the most out of their musculoskeletal benefits. Our digital musculoskeletal (MSK) platform 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. MSK triage ensures that members get help and advice to pick the right treatment at the right time. 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. 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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