Digital MSK care, digital therapeutics, clinical MSK solution, telePT, COEs – it is getting too complicated for a segment that we all would like to make simpler. We thought it was time to create a blog post that could serve as a holistic glossary for musculoskeletal benefits — one that not only defines each term, but also offers some helpful resources in case you want to learn about them in more depth. We hope you can bookmark this post and come back to it whenever you need to.
Behavior health and chronic pain conditions are very closely linked. Many of the neural pathways used in processing chronic pain are also used for anxiety, depression and grief. Over a long period of time, the brain may conflate the two experiences, making it almost impossible to distinguish between them.
Behavioral health support helps members cope with the thoughts, feelings and behaviors that accompany chronic pain.
Bundled payment programs give providers a single target budget or price for an “episode” of care. The Centers for Medicare and Medicaid Services (CMS) defines an episode as “a set of services provided to treat a clinical condition or procedure, such as a knee or a hip replacement.”
Commonly used for elective surgeries with predefined start and end points, bundled payments can be either prospective or retrospective. Within a prospective bundled payment model, the musculoskeletal benefits administrator pays a single upfront payment to providers or health care facilities (or jointly to both) for all services to treat a given condition or to provide a given treatment. while in retrospective payment models, the musculoskeletal benefits administrator pays providers incrementally through fee-for-service, then reconcile the total episode cost against a predetermined budget at the end of the episode.
Centers of Excellence
Centers of Excellence (COE) are designated groups of providers that meet high standards for both the quality and the cost of care for a particular service or set of services. There is a high degree of variation in cost and quality in musculoskeletal care. The COE programs address these variations for particular high-cost or highly-specialized services. Having access to COE programs enables members to select care from a site offering high-quality, more affordable care.
In one example, under the COE program, Walmart covers the full cost of travel and treatment for employees seeking certain common elective surgeries such as hip, knee replacement, and spinal procedures. Walmart employees (and covered family members) must agree to seek care at a designated center of excellence (hospital). Walmart then reimburses the COE via bundled payment agreement.
Chronic musculoskeletal (MSK) pain
Chronic or persistent pain lasts or recurs for more than 3 to 6 months. Chronic pain is the number one cause of adult disability in the United States, and musculoskeletal pain—especially joint and back pain—is the most common single type of chronic pain.
A number of people with chronic pain have comorbidity, and the two most common co-morbidities of chronic pain are depression and anxiety. These two factors (pain and depression)is the leading cause of absenteeism (employees missing work). Chronic pain is expensive. The number of provider visits by people with chronic pain are two times the visits by people without chronic pain. They also have a considerably higher utilization of urgent, emergency, radiology, drugs and surgical care.
The successful management of chronic pain relies on a multidisciplinary and holistic approach aimed at both minimizing pain as much as possible and empowering people how to live well with chronic pain. This multimodal approach incorporates a biopsychosocial formulation with physiological, cognitive, behavioral, and emotional components.
Coinsurance is member’s share of the total cost of the service. Defined as a percentage (%), health plans use this instrument to encourage low (er) cost services over high (er) cost services for a certain condition. However this ‘skin in the game’ concept is a misnomer. Members often don’t know the cost of the service until weeks/months after the service is used and hence are unaware of their % contribution at the point of care.
Connected musculoskeletal care pairs technology and clinical support to provide continuous, connected and on-demand care that aligns with the 24/7 demands of chronic pain. It enables real-time, electronic communication between a member and her providers and includes video sessions, remote monitoring, and secure messaging in-between sessions. Connected care improves access, helps members avoid costly injections and surgeries, and increases convenience.
A copay is a flat fee you pay for each visit. Health plans use this instrument to increase/decrease utilization of services. The copay has been steadily going up in the last few years. A number of plans now have over $50 copay for physician/specialist/PT visits, which acts as a deterrent.
Ideally copays should be aligned to treatment value and provider effectiveness rather than a set amount. However, in absence of such nuanced plan design, the right copay for physical therapy is between $0 and $20 and members with copay over $30 are 29% less likely to see the PT than the ones with $0 copay.
Digital health capture and data analytics have created unparalleled opportunities to assess and modify health behavior and thus accelerate the ability of technology to influence health behavior and health outcomes. Data-driven system is built around the member. It collects and analyzes signals at various points in the member’s journey and uses this knowledge to support members with interventions that are likely to improve their outcomes.
Data analytics puts the right information in front of the right people, at the right time. It enables users to get at the information that they need to make informed data-driven decisions.
In addition, the analytical tools routinely check data against key quality measures, identify gaps in care and generate appropriate alerts for members, caregivers and administrators.
Decision Support Tools
According to AHIP, nine out of ten adults in United States have difficulty using health information to make informed decisions about their health. Navigating our complex, fragmented, medically interventional system is especially hard for people with pain who have complex needs. They often face multiple handoffs between providers and tremendous uncertainly at every turn.
As an alternative to incomprehensible plan documents, the decision support tools for musculoskeletal care helps members and their families make good decisions around benefit elections or treatment paths for their condition at any point in time during the year.
The deductible is the amount a member pays out of pocket before her health plan will cover any portion of care (outside of deductible exempt services such as preventive care). Deductibles create barriers and get in the way of high-value care (for example preventive care or using PT for musculoskeletal conditions) as much as low-value care (for example visiting ER for low acuity back pain).
Ideally musculoskeletal (MSK) benefits should not have any deductible. If a member has fibromyalgia, it does not disappear in Jan when the deductible resets in most plans. There are many other plan design tools that are more effective in managing suboptimal utilization.
Digital Navigation for MSK Care
At the time of enrollment, members often don’t know what they (or their family) may need during the year. While benefit leaders are spending a lot of time and money bringing new and innovative programs that can help members, unfortunately they often don’t know about them at the time of need. That’s why the engagement level of these programs is quite low.
Digital navigation for MSK care serve as a one-stop shop to help navigate members to the right musculoskeletal care solutions at the right time. This may include virtual physical therapy for minor aches and pains, chronic pain management for members who are experiencing pain persistently over a long time, or access to expert opinions before surgery etc.
Digital Therapeutics for Musculoskeletal Care
Digital therapeutics for musculoskeletal care includes evidenced-based therapeutic interventions which leverage software to prevent, manage, or treat a musculoskeletal condition, in lieu of conventional treatments (eg, opioids, injections or surgery)
A digital care program for chronic pain management is an example, that uses a multi-modal approach (including education, behavioral health support, health coaching and physical therapy) to help members reduce back and joints pain and improve function.
Most employers are getting poor ROI of their healthcare investments. The premiums keep going up and the benefits don’t feel like benefits. There are several reasons for ever-increasing costs, including sub optimally designed provider networks and fee-for-service payment models.
Direct contracting can help employers take direct control over the cost of care, define and measure the metrics and align the payments to their provider partners.
Learn about our services to assist employers with direct contracting efforts with musculoskeletal delivery systems (such as surgery centers, hospitals, pain management clinics) for the purposes of Centers of Excellence, bundled payments and more.
A surgery is elective if it can be scheduled in advance. Elective does not mean “optional”. Most elective surgeries are done to improve quality of life. It may be a surgery you choose to have for a better quality of life.
One of the benefits of elective surgeries is the days or weeks members have to improve their health before their scheduled procedure. Since surgery can be a physically demanding experience, prehab (prehabilitation) can lead to best outcomes. Research has indicated that hip/knee surgery patients who undergo prehab are 73 percent less likely to need inpatient rehabilitation.
Statistics show that average American takes less than 30 minutes to make benefits decisions—and in that brief time, 89% of people choose the same plans as the year before.
Benefit leaders are constantly working towards delivering programs that support the unique needs of employees and families. Unfortunately, most employees are not able to utilize these programs to their potential. The one-size-fit-all approach taken by health programs makes them unfit to meet the unique needs of most employees.
Employers and health plans need to provide a simplified experience that reduces the amount of effort required on the part of the employee to access programs and information, and make it easy for employees to engage in their health and take advantage of the programs available to them.
Expert Medical Opinion
Finding out you may need surgery can be daunting for any one of us, and getting an expert second opinion can help putting our mind at ease, especially when we feel unsure about our treatment options.
When you’ve received a diagnosis of a complex orthopedic condition, it’s valuable to seek a second opinion. Even if the second opinion just confirms what you already know, it can still be beneficial. A second opinion can also offer insight into additional treatment options to help members make informed decisions and feel confident in what they choose.
Learn more about our musculoskeletal assessment and triage services that provides access to members struggling with a surgery decision to have their medical case reviewed by experts to confirm a diagnosis and/or treatment plan, or to offer an alternative.
High Performance Networks (HPN)
Traditional PPO, HMO, EPO networks are very generic and not designed around the needs of your employee population. For example, even though the pain profile of trucking company’s employee population is very different from yoga studio, yet the musculoskeletal network design looks alike in both cases.
A number of employers and health plans are now experimenting with narrow, tailored, tiered and other types of health networks designed for employers to tap into for greater efficiency. The basic idea behind designing such networks is to spend less by negotiate value-based agreements with a limited group of providers and steer members to these handpicked providers.
Learn more about designing employee-centric networks by identifying high quality, high-value providers nationally or in certain geographies, around the needs of your employee population.
Multimodal therapy or program
Multimodal therapy is based on the idea that the therapist or the program must address multiple modalities of an individual to identify and treat a disorder. People with chronic have complex needs and often their psychological symptoms are at the forefront of their pain experience. That’s why despite high frequency of physician, PT visits and high medical spend, these people do not respond well to the traditional medical model of care.
The modern holistic approach to chronic back and joint pain management includes multiple types of interventions working together including physical therapy, self-management, behavioral health support and tailored education.
Omnichannel experience is an integrated and cohesive healthcare experience no matter how or where a consumer reaches out for care or support. It is different from multichannel experience which is about providing same experience on different channels.
Persistent musculoskeletal utilizers (PMUs) are a small group of members who impose a disproportionately high burden on the musculoskeletal spend due to their elevated resource use. 35% of musculoskeletal (MSK) spend is concentrated among 4% persistent utilizers. These high need high cost group often have complex conditions and co-morbidities. The key characteristic of this group is low self-esteem and self-efficacy, both of which can’t be addressed in our fragmented medically interventional system.
Most elective surgeries in US have several weeks or months between scheduling and the day of surgery. This is the best time to get in the top physical and psychological condition possible, for better surgical outcomes and faster recovery times. 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.
The goal of postoperative rehab is to get you back on your feet after surgery, 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.
Typically the postoperative rehab includes physical therapy (to increase strength, mobility and fitness), occupational therapy (to help perform day-to-day-activities) and pain management (reduce pain and discomfort).
Remote Physical Therapy
In remote physical therapy (sometimes referred as remote musculoskeletal care) the care is delivered remotely in an asynchronous manner. Unlike traditional episodic care delivered in-person or over video where both parties (patient and doctor) are in live two-way interaction, in the remote musculoskeletal care, the patient and provider can exchange information over secured messaging, email.
Remote MSK therapy also provide app-guided exercises to members at home and include an automatic monitoring system to measure adherence. The range of motion (ROM) and other clinical data are collected and transmitted for review by physical therapists remotely. This enables physical therapists to see if their patients are completing their plan, help them coach their patients and do more to customize their therapy plans. If a patient is off balance or moving incorrectly, remote MSK solution provides feedback to the patient and flags the issue for their clinician.
Surgical care pathway
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.
A modern data-driven surgery pathway integrates three complementary processes (outside the surgical setting) in the member’s surgical journey.
- Shared decision making
- Prehabilitation (Prehab)
- Rehabilitation (Rehab)
Telerehab (sometimes referred as virtual physical therapy or virtual rehab) helps individuals manage musculoskeletal conditions with personalized online exercises and video visits with physical therapists. It uses technology to perform a scan of the patient in order to measure their movement and analyzes their functional assessment. Both patients and providers are able to view a user’s progress and statistics on a dashboard.
Here’s how it works: The physical therapist sets an exercise prescription like they do now, but instead of static paper handouts the patient receives her prescription in a rich, engaging application. The application guides the patient through her prescribed exercises, providing feedback and encouragement in real time. That information is then reviewed by the physical therapist, where they can review patient results and update the prescription (as needed).
Transparency solutions provide healthcare price, cost and sometimes quality transparency to employers and/or their members. Given that healthcare services are billed after the visit (fee for service with managed care discounts) in United States, the rough estimates provided by traditional transparency tools have limited value for most musculoskeletal treatments.
Employers and health plans should consider plan designs that provide certainly of member costs for each treatment option. These costs should be made clear in advance for comparing different treatment options, with an experience designed to help them make good decisions.
Learn more about our MSK financial management tools that aligns employee’s out-of-pocket costs with the value of the health services.
The basic version of musculoskeletal triage tools provide support in searching for and scheduling appropriate care based on symptoms/ conditions as well as price and quality of providers.
An advanced version of physical therapist-led (PT-led) orthopedic triage is an evolving model of care for patients with musculoskeletal conditions. In this model of care, a physical therapist assesses, diagnoses and manages patients referred for orthopedic consultation. This review by an MSK specialist ensures that patients are seen in the most appropriate setting across the primary and specialist care.
Learn more about our MSK assessment, triage and referral solution that provides help and advice to pick the right treatment first time
Value-based Insurance Design
Value-based insurance design (VBID) lowers or removes financial barriers to essential, high-value clinical services and align members’ out-of-pocket costs, such as copayments and coinsurance, to the value of services.
VBID have proven successful in encouraging healthy behaviors and reducing health care costs.
Virtual Physical Therapy
Not every injury is suitable to virtual care, any soft-tissue injury that inhibits movement can be improved through virtual physical therapy. A soft-tissue injury is an injury that does not affect the bone. Examples include sprain, strain, swelling or bruising and even back, shoulder and neck pain. To address such issues, consumers do not need to see their Primary Care Provider (PCP) in most cases.
There is a large amount of research that demonstrates better long-term outcomes at lower cost when treatment for musculoskeletal pain or injury starts with physical therapy. Virtual physical therapy provides quick, safe access to an extensive network of licensed physical therapists, and connects the consumers to the care they need with the press of a few buttons.
Virtual Urgent MSK care
Virtual urgent musculoskeletal (MSK) care can be a good alternative to emergency department (ED) visits, urgent care visits for lower acuity back and joint pain and injury. This service allows the consumer to remotely consult a musculoskeletal (MSK) specialist to address immediate concerns (such as an ankle sprain) and avoid a trip to the ED or an urgent care center.
As more people are doing work at home for extended periods, providing them quick access to MSK specialists is essential for those who develop knee, hip, back and shoulder condition. They can get quickly assessed via messaging, video or telephone channels and receive sensible suggestions to relieve their symptoms.
Virtual Value Networks
Virtual value network solution enables members to select high-value providers based on quality and cost.
Learn about data-driven approach to design musculoskeletal network around the specific needs of employer’s member population.
Over 50% of the health spend is wasted and in the musculoskeletal category, most of this waste is concentrated in surgeries, imaging and drugs. 80% of the waste is recoverable. Therein lies the biggest opportunity. When employers and health plans reduce waste, they spend less, and hence bring the insurance premium and cost-sharing down for everyone. Waste management solution assist employers and health plans to identify fraud, waste, and abuse in an employer’s healthcare costs like overcharging for services or providing medically unnecessary services.