In the COVID-19 era, benefit leaders are struggling to find the right composition of their 2021 benefits package amongst complex, unknown, and ever-changing workforce challenges. Despite the challenges, there has never been a better time to rethink the benefit design that would meet the evolving needs of future. A future where the workforce will likely spend a considerable amount of time online, at home.
The pragmatic employers and health plans are looking inside their black box of benefits and picking areas of potential opportunity, where they are getting poor value for their investments. Musculoskeletal (MSK) is one of those benefits for most of them. Musculoskeletal (MSK) conditions are highly pervasive (1 in 2 adults have it in a year), highly expensive (15 – 20% of annual spend) and highly wasteful (50% of total spend is waste).
Employers and health plans need a fresh approach. An approach built on first principles that addresses two things – a) provide high quality musculoskeletal (MSK) care to ALL of their people, anywhere and anytime and b) reduce the cost by eliminating waste.
This approach is digital-first, meaning it provides the care quickly, uses virtual models to deliver care in the safety of people’s home. This approach is integrated, and provides support for all MSK conditions, at any stage (acute, chronic, surgical or post-surgical) across the continuum. This approach is tech-enabled and data-driven. It uses dashboards and predictive analytics to inform benefit operations and infrastructure; and uses this data to design high impact strategies to produce high-quality outcomes at lower costs.
This systematic approach to optimizing musculoskeletal (MSK) benefits can be divided into 10 steps.
STEP 1: WASTE ANALYSIS
No one likes to waste money. In this environment where a number of businesses have lost customers and revenue, wasting money should be considered a sin. Yet, over 50% of musculoskeletal (MSK) spend is wasted, which can be attributed to a number of factors including inappropriate tests and procedures and price variation.
The musculoskeletal (MSK) health system is United States is highly fragmented and interventional. People with MSK conditions have varied needs (based on severity of their issue, co-morbidities etc.), and they face a system which is highly medicalized. For example, even though it is widely known that physical therapy should be the first-line treatment for most MSK conditions, its utilization is under 15%. Most specialists in pain medicine, orthopedics don’t encourage patients to explore conservative treatments even when it can be in their best interest.
To optimize spend, an effective digital MSK system provides deep insights into where you are wasting money. It evaluates every test and procedure for appropriateness to ensure it contributes to advancing the people’s health. In addition, it highlights high-value providers and services who provide quality services at lower costs.
STEP 2: FORECASTING & TARGETS
Health benefits is probably the only function in businesses which does not use a proactive approach to cost management. The next year’s cost projection is essentially based on past claims and medical trend. Underlying condition profile and cost-driving factors are not often considered at renewal.
Having targets aligns everyone (benefit leaders, consultants and vendors) to a common goal and brings the necessary discipline required to systematically improve cost and quality outcomes.
To optimize spend, a digital MSK solution enables benefit leaders to set cost, quality and outcomes targets. It includes a forecasting feature to guide them where the cost is heading for the remainder of the plan year. The visual dashboards in the system provides real-time visibility into how actuals are lining up against the forecast and flag specific areas that should be addressed to hit the targets.
The more precise and real-time understanding of musculoskeletal benefits performance makes it possible to fine-tune your strategies in accordance with the new and evolving needs of your population anytime of the year.
STEP 3: POPULATION SEGMENTATION, RISK STRATIFICATION
20 percent of the member population accounts for over 80% of overall musculoskeletal spend for an employer. To control cost, it is important to find the best ways to meet these members’ needs. While some of these high-cost, high-needs members are easy to find from data (4% of members contribute to 35% spend over two years, persistent high-cost members), majority of high-cost, high-need members are difficult to spot in time in any given year.
A data-driven musculoskeletal care solution uses predictive modeling and analytics for segmentation and risk stratification. Both concepts together help understand the musculoskeletal needs of each sub-segment, so interventions and services can be better planned.
Segmentation is grouping people by what kind of musculoskeletal care they may need as well as how often they might need it. The digital MSK health solution analyzes past claims to understand what services were used by members in each segment, and the main combinations of care that people might need in future. It supports prioritization and a phased approach to implementation. The segmentation can be done by age/gender, acuity (acute, chronic, rehab), office (location x vs. location y), conditions among other options. Grouping people by MSK health conditions (state and stage) distinctly identify each group’s needs from another.
In addition to segmentation, a digital MSK health solution enables risk stratification to provide an understanding of members who have the greatest risk of utilization of expensive services such as surgeries, injections etc.
STEP 4: MUSCULOSKELETAL (MSK) TREATMENT PATHWAYS
The outcome of population segmentation is a set of needs per segment.
To optimize benefit composition, an effective musculoskeletal solution uses a pathway approach to each need. These pathways define predictable course, in which the different tasks or interventions are defined in a sequential manner. Pathways can be measured for cost and quality, and optimized over time.
Both virtual and in-person high-value services are considered, for each intervention. For example, while the initial MSK evaluation be done virtually, both in-person and digital therapy options are considered for treatment.
For each intervention, the digital MSK care solution identifies providers based on cost, quality and access. For example, in the surgery pathway, the surgery centers of excellence (COE) are identified based on highest quality, lowest cost and proximity to the target population.
STEP 5: MUSCULOSKELETAL (MSK) NETWORKS
Most provider networks are designed from the carrier’s perspective (cost and network adequacy goals) and are not flexible to meet the needs of employers and their member population. A digital MSK care solution takes the data-driven approach to design musculoskeletal network around the specific needs of employer’s member population in each segment, as manifested in the care pathways.
It is not scalable to build network partnerships for each single service. The digital MSK care system consolidates providers across multiple interventions based on the volume of ‘high-value’ needed services. Consolidating providers helps in clinical integration as well as care coordination. The goal here is to find the highest quality, lowest cost, most accessible, clinically integrated providers who provide high-value services that meet the needs of your people. One underlying assumption in the musculoskeletal (MSK) network design is that all selected providers can electronically interface with each other across the MSK continuum to exchange utilization and quality data.
STEP 6: PAY FOR VALUE
Unlike traditional PPO networks that pay providers based on fee for service models, an effective digital MSK health solution aligns provider payments to performance and value (quality/cost).
The numerator ‘quality’ is built on expected outcomes, response time, member experience relevant to your employees’ needs & clinical conditions.
It utilizes machine learning models to assess which value based payment models best meet the company’s budget and address the quality and cost expectations.
These models includes P4P, risk-adjusted primary care, severity-adjusted bundles, shared savings, etc that reward providers for good outcomes and high quality, not medical errors, unnecessary procedures and other low value care.
STEP 7: BENEFIT AND INCENTIVE DESIGNS
A digital musculoskeletal (MSK) solution promises a high-value musculoskeletal care, which delivers better outcomes and lower costs. Since it is often offered as an add-on option, the employers and health plans create benefit and incentive designs to incentivize members to use these high-value services. Some organization waive the copay, some others provide rewards when members these services.
The digital MSK health solution provides maximum flexibility in experimenting with benefit designs to align member incentives. This enables companies to implement new approaches such as value-based-insurance design (V-BID), reference based pricing to align member’s out-of-pocket costs with the value of the health services. This leads to a win-win situation for plan sponsor and the member.
STEP 8: MEMBER ENGAGEMENT
An effective digital musculoskeletal (MSK) therapeutics solution enables benefit leaders to market and communicate the solution benefits in a timely, personal and meaningful way to their people. It provides an intuitive user experience for employees to quickly sign-up and start using the services.
The system uses behavioral health science, along with rewards and member incentives, to motivate members to actively engage with their health. It leverages intelligence tools to proactively identify members who need recommended care and initiate customizable notifications regarding follow-up therapy sessions or behavioral health support. By engaging the member with the right message and the right incentives, it motivates members to complete high-value activities – leading to higher adherence.
In addition, the solution improves health outcomes with a proactive, collaborative and continuous care coordination approach that creates a personalized care journey for each member to address their specific needs.
STEP 9: DATA STREAMING AND COLLECTION
The technology architecture of a digital musculoskeletal (MSK) system is centered with the member at the center. It ensures that all stakeholders are connected with data that is accurate and timely.
A digital MSK therapeutics uses video chat and messaging, interactive education using videos, motion detection (and capture) using camera to better support members in their recovery and improve adherence and ultimately, clinical outcome. The therapists gain a lot of actionable data that assists in their management of each case and shift to a more proactive approach to health care.
Digital MSK therapeutics also changes the way care is provided, with the member completing regular outcome scores online, and an increase in pain flagged to the therapist remotely, giving the clinician an opportunity to make an informed decision at the right time.
STEP 10: REPORTING AND ANALYTICS
Data-driven decisions are smarter decisions. A digital MSK solution does the heavy lifting to infuse intelligence into your everyday workflow, and provides empirical evidence to truly understand the impact of your musculoskeletal investments. Easy-to-use reporting and advanced analytics provides actionable insights and savings recommendations to benefit leaders to help them make informed decisions. The dashboards provide real-time understanding of enrollment, engagement, utilization, spend and outcomes.
In addition, the analytics assesses the effectiveness of care management interventions, identify compliance with evidence-based care standards and compare the utilization and financial results of people participating in digital MSK health programs with those who are not.
Sprite health helps employers and health plans get the most out of their musculoskeletal benefits. Our 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. 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.