How digital care optimizes the musculoskeletal surgical pathway?

Have you ever called a surgeon’s office for yourself or your loved ones? This is how it goes –

Press 1 if you are a provider, Press 2 to schedule an appointment, Press 3 if you are an existing patient and Press 4 for billing or claims.

There is no option for you to talk to someone who can help you understand the process and explain what is right for you. Someone who is on your side when you are unsure and scared. If you press 2 and schedule the pre-surgical appointment, more than likely you’ll be heading down surgery even if that may not be in your best interest.

Millions of musculoskeletal (MSK) surgeries are performed in United States every year. Most MSK surgical pathways in practice are focused around provider, rather than member’s convenience. There are wide differences in quality and cost among facilities and surgeons who perform these surgeries. Despite the enormous cost of surgery (many of them cost over $50K), unfortunately most members routinely experience complexity and multiple handoffs across different providers. Most often they don’t have any health advocate on their side, and they have to figure things out on their own.

Employers and health plans are awakening to this realization and are demanding better value for their healthcare spend. While bundled payments with centers of excellence (COE) facilities are a great start, much more is needed to make the process better that improves member experience and lowers costs by eliminating waste.

Unlike traditional model of care, digital musculoskeletal care platform takes a member-centered approach to surgery to maximize best outcomes. This means that members are more educated and engaged in their care and recovery, more happier with their care and achieve better functional outcomes, with less complications. In this model, the surgical pathway begins much earlier than the traditional model – it starts when members first contemplate surgery in primary care or a surgical clinic and culminates weeks to months later on the day of surgery.

It’s widely acknowledged that the most important component of successful surgical outcome is what a member does when they are not in the surgery. The digital care program optimizes the musculoskeletal surgical pathway by integrating the following three complementary processes (outside the surgical setting) in the member’s surgical journey.

1. Shared decision making
2. Prehabilitation (Prehab)
3. Rehabilitation (Rehab)

SHARED DECISION MAKING

The only surgery without risk of complications is the one not performed. Shared decision-making (SDM) is a process whereby members and clinicians work together to make evidenced based decisions centered on member’s values and preferences. Shared decision making explicitly acknowledges that there is usually more than one way to treat a problem, including ‘no treatment’. In our fragmented and wasteful system of care, members most certainly require support to understand the benefits and harms of the options in order to determine the best choice for them.

Digital musculoskeletal care program facilitates the shared decision making to ensure that the right decision is made in relation to the surgery and ensure that the member is well prepared for the surgery.

These goals are best achieved if members are guided about their options earlier in the pathway to surgery. Ideally such engagement occurs at the time of initial diagnosis or when the member decides to choose a specialist such as orthopedic surgeon.

At the right time, a dedicated musculoskeletal (MSK) clinician speaks to the member before major surgery (such as total hip and total knee replacement). The clinician enables the member to understand the implications of surgery, ensures that conservative measures have been optimized, surgical thresholds are met and that the member indeed wants surgery and is prepared for it. At this stage, the clinical also explains non- surgical alternatives.

This collaborative approach enables members to be fully informed about their care. Members who are effectively involved in making decisions about their care have fewer regrets about treatment, better communication with their healthcare professionals, improved knowledge of their condition and treatment options, better adherence to the selected treatment and an overall better experience.

Innovative employers such as Walmart have implemented shared decision making very creatively. When designing the payment arrangement with centers of excellence (COEs), Walmart went to great lengths to ensure that the COEs
would be motivated to deliver only appropriate care and cut out waste. The surgery program consists of two separate non-overlapping prospective bundles. The ‘evaluation’ bundle which essentially pays providers for evaluation and guidance and surgical bundle which pays for surgery. This approach helped Walmart mitigate some of the financial incentive to perform unnecessary surgeries for members who should seek alternative treatments.

PREHABILITATION (PREHAB)

A successful outcome begins before surgery. After a member has chosen to go ahead with surgery, prehab or prehabilitation should be the next step of the member’s journey that leads to best outcomes.

It should not be a surprise to anyone that beginning the surgical journey in the best physical and psychological condition helps getting to better surgical outcomes and faster recovery times. Research has indicated that hip/knee surgery patients who undergo prehab are 73 percent less likely to need inpatient rehabilitation. Just one or two sessions of preoperative physical therapy reduced the use of post-acute care services by nearly 30%. Despite mountain load of evidence, very few surgical facilities encourage prehab. Most surgery assistants don’t even know if that exists.

Most elective surgeries in US have months between scheduling and the day of surgery. Ideally, it should begin at least six weeks before an elective surgery (like joint replacement, ACL repair, back surgery, shoulder surgery etc.).

The digital care program for prehab includes interventions such as initial contact with the members to gather relevant information about their readiness. Unlike the traditional approach where the members are pretty much left on their own, in the the digital musculoskeletal program the care coordinator maintains communication with the member throughout the waiting period with regular messaging. The lead physical therapist undertakes a holistic assessment, and identifies any comorbidity that may impact on the surgery. In addition, the members are provided relevant education to improve their physical condition.

Working with a physical therapist, the member receives a personalized exercise program through an engaging cloud-based applications that could be accessed through a desktop computer, tablet or phone. The exercise program is geared towards putting member in the best possible position to recover from surgery. Depending upon the member’s needs, the prehab program may include a weight-loss regimen (especially in the case of joint replacement surgery) or it may simply be focused on strengthening the body.

Prehab also gives members a chance to practice the post-operative exercises they’ll be expected to do during their rehabilitation. Members learn techniques on movements with new weight-bearing precautions or mobility restrictions they’ll likely have after surgery.

Overall, digital musculoskeletal care program for prehab empowers the member to be proactive about the surgery, make her an educated and more well-informed member, and shortens the recovery time.

REHABILITATION (REHAB)

After the member had a surgery, a course of post-surgical rehabilitation will continue the good work they started with prehab. The goal of postoperative rehab is to get you back on your feet, so you can continue living a healthy and independent life. It includes a personalized treatment plan shaped to your individual needs, including the type of surgery you are recovering from and any other medical conditions you may have. Digital care program for rehabilitation often includes three key elements: 

1. Physical therapy to increase strength, mobility and fitness
2. Occupational therapy to help the member perform day-to-day activities
3. Pain management to decrease discomfort

For most members, digital rehab is a better way to get healed after surgery. Even though physical therapy is often uncomfortable right after surgery, it is far less painful than waiting to begin rehabilitation.

Getting started with rehab early after surgery is key. If members see good outcomes early, they feel more confident and optimistic throughout their recovery. In most cases, the digital care program initiates virtual physical therapy within 24 hours of the procedure and may continue for up to three months following surgery.

After the initial assessment of balance, strength, ROM and functional level, the members receives an exercise plan from the physical therapist, that is customized to his or her needs and fitness level. The exercise plans is made up of video exercises in the app, rather than the traditional stick figures provided in in-person setting. The system helps member stay compliant with their treatment. This connected care model enables members to monitor their progress and communicate with their therapist anytime. If a member reports a high pain level, the therapist is alerted. If a member is struggling, the exercise regimen is adjusted. The core aspect of post-surgical rehabilitation is doing the right exercises and the right amount of exercises. The intensity of the stimulation increases gradually and progressively.

In short, digital musculoskeletal care for prehab and rehab helps members retrain and strengthen the muscles, ease them back into daily physical tasks, prepare their body for regular exercise, speed overall recovery, reduce pain, improve mobility and flexibility and prevent new medical problems from forming.

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.