Musculoskeletal (MSK) conditions make up a large portion of annual health spend for most employers. 1 in 2 employees experience musculoskeletal pain in any given year. 40% of them are misdiagnosed and despite medically interventional treatments (82% of MSK spend is on surgeries, imaging and drugs), over 50% of them are back in the system within a year with the same issue. Clearly the traditional musculoskeletal benefit is delivering poor return on investment for employers.
The problem with MSK benefit exists on all sides. First let us talk about the network design. Instead of designing the musculoskeletal (MSK) network around the needs of employee population, the medical networks are often very generic. The pain profile of trucking company is very different from yoga studio, yet the musculoskeletal network design looks alike in both cases. The broad PPO networks are often designed with no criteria and narrow networks are designed with one metric – unit cost. This approach is not working for employers. It is well known that healthcare in US does not operate like a free market economy. Through mergers and acquisitions, providers have accumulated large market power in most geographies around the country. They understand the discounting game quite well and often respond by either refusing to discount or increasing utilization of services.
Plans respond to utilization by creating barriers – preauthorization for providers and cost-sharing for members. The pre-auth and cost-sharing structure is quite basic, and lacks member condition specificity. For example, members face the same deductible barrier whether they use a high-value service or not. They pay the same copay (or coinsurance) for a speciality whether they visit a good provider or not. The generic pre-auth and cost-sharing sledgehammer approach impacts the utilization of both necessary and unnecessary treatments. Unfortunately this tit-for-tat game between health plans and providers has resulted in ever-increasing costs, poor member experience and suboptimal health outcomes.
The musculoskeletal benefits should redesigned around the most important constituent – the employee. Employees with pain have complex needs. They often don’t know where to start when they experience pain and navigate a fragmented, uncoordinated, interventional system, with uncertainty at every turn. This results in significant waste of time and resources for both employees and plan sponsors.
By designing a benefit around employees instead of doctors, treatments and facilities, the focus shifts from controlling utilization and cost to improving outcomes and member experience. This approach puts employees’ needs at the center and include treatments and providers that best respond to those needs.
Let’s go through the top 10 features of a new-age, employee-centric, outcomes based musculoskeletal benefit solution.
- Self-care and prevention
Let’s start with the obvious. Many musculoskeletal conditions can be prevented before they occur. The MSK benefit solution must include support for self-care programs that use science-derived best-practices to help employees prevent onset of pain. These MSK prevention programs should ideally be 100% subsidized and fit seamlessly into employees’ daily routines. In addition to prevention, these programs should include medically-validated self-care guidelines for minor aches and pain, delivered via short learning modules using interactive videos.
2. Rapid access to assessment and advice
Even with a sound self-care and prevention program, people are likely to develop back and joint pain. When they do, a delay in right treatment leads to bad clinical and financial outcomes. Musculoskeletal (MSK) benefit solution should include generous coverage for quick access to conservative treatments such as physical therapy or chiropractor.
Research demonstrates that for most people if the physical therapy starts later (two to three weeks after the onset of pain), it leads to higher claims costs and longer disability. Conversely introducing PT early creates a ripple effect – reducing the need for surgery and reducing the likelihood of opioid-use to manage pain.
However, the goal should not be to unnecessarily initiate physical therapy in more members, because that will lead to more costs. The key is to identify the members that will get the best clinical benefit from physical therapy services. The optimal number of sessions should be based on individual member’s needs, effectiveness of physical therapy, and therapist efficiency to address that need. It is the difference between optimizing utilization versus merely controlling it.
3. Broad understanding of member’s condition for accurate diagnosis
In our current system, where you start your journey determines your outcomes. The care strategy each member receives is predicated upon which door she walks into. In a traditional model of care, a linear approach to pain management is followed: Identify the diagnosis and then apply treatment to that diagnosis. If the first treatment does not work, apply the second one and then the third one. If it takes time, the member already feels disabled and is frustrated by lack of progress.
Pain is complex. Given that 40% of MSK conditions are misdiagnosed, musculoskeletal benefit solution should include support and payments for care pathways that lead to accurate diagnosis. The idea is to move toward taking a holistic approach to pain and taking psychosocial and socio-economic barriers into consideration.
4. Active participation by the member
How an individual thinks about her pain has as much to do with outcomes as the treatment.
Members can sometimes be the greatest barriers to their own recovery. Fear avoidance is a very real challenge faced by many members in physical medicine programs. High-level evidence supports the association of fear avoidance beliefs with poor treatment outcomes. Conversely, when these beliefs are addressed with the member, treatment efficacy is more likely to improve. The ability to identify and address these negative risk factors goes a long way towards increasing the odds for positive outcomes.
The musculoskeletal benefit solution should provide a structured approach that makes the member an active participant. This can make a big difference in decreasing costly and unnecessary diagnostics & other interventions. To get member to be more engaged in the care, the care model has to evolve from passive paternalistic transactional process to proactive advocacy approach. The payment model should be redesigned to ensure that patient values guide all clinical decisions across the care continuum.
5. Multimodal care
For employees with musculoskeletal (MSK) pain, psychological symptoms are often at the forefront of their pain experience. In these moments, empathetic behavioral support can make all the difference. The musculoskeletal benefit solution should provide coverage for multimodal care programs that combine education, exercise therapy and behavioral support is key.
The pain education shifts the focus from pain to function. The exercise therapy helps decrease the pain, improve function and strengthen the body. Great results are achieved by providing people with 1:1 compassionate support from a health coach, who encourages them to focus on activities they enjoy and want to return to, and provide them with consistent messaging so they trust and believe in their course of treatment.
The health coaches are able to recognize and address members’ anxieties. Skills like motivational interviewing and therapeutic listening help get to the root of their emotional or psychological distress. Incorporating these factors into the care plan is critical for a smooth and faster recovery.
6. Team-based collaboration
Whether it’s acute, chronic pain, or complex injury – employees routinely experience complexity and multiple handoffs. Without any health advocate on their side, they have to figure things out on their own. It is imperative that the the employees are hearing a consistent message from all stakeholders.
“My therapist told me one thing. My doctor told me something else.” This makes the member very confused.
The musculoskeletal benefit solution should provide a team-based collaborative approach that fixes this problem. When rehabilitation specialists, orthopedic surgeons, caregivers, and the member are on the same page on progress towards functional goals, magic happens.
This approach improves patient satisfaction and reduces administrative, and clinical costs.
7. Data-driven outcomes & clinical oversight
Instead of limiting the number of visits in the musculoskeletal benefit design or pre-authorization, it is far better to start with a treatment goals. In order to assess the effectiveness of musculoskeletal care in achieving those goals, there must be in place objective measures of clinical progress: range of motion, strength, return-to-work, self-efficacy, psychological distress, sleep interference, interference w/ daily life & satisfaction w/ care.
If these aren’t being measured, then clinical progress towards desired outcomes is not truly being assessed. Yet these measures have often been missing from traditional provider performance.
Also, there is no use continuing with the treatment if it ain’t working. If there is no progress made in the defined time period (say 2-3 weeks), it is time to change the course. The outcomes should be collected and reported at multiple touch points to accurately assess quality along the care continuum.
8. Value-based payments
To reduce musculoskeletal spend, the payment model has to evolve from volume of care to outcomes of care. Under a fee-for-service system, the metrics commonly measure volume. This leads to perverse incentives and waste.
The musculoskeletal benefit solution should support value-based payment models that reimburse providers for outcomes. Rather than focusing on number of visits or per visit cost, these value-based payment models focus on evaluating effectiveness vs ineffectiveness of treatment. Effective therapy means adherence to evidence-based and outcomes-focused treatment. A recent analysis conducted on 100K patients who received physical therapy for low back pain clearly demonstrated that patients who received therapy adherent to evidence-based guidelines experienced lower utilization of physical therapy visits (6.2 vs 15.0), advanced imaging, lumbar spinal injections, and lumbar spine surgery compared with patients receiving physical therapy services that were discordant with guidelines. Overall LBP-related costs, as well as prescription medication costs, were also reduced for the guidelines-adherent population.
To pay providers on quality vs quantity, the value-based payment model can be based on either risk-adjusted episodic cost or a fixed bundle cost – adjusted for health outcomes. Value-based payments can have a drastic impact on the optimization of musculoskeletal care and patient outcomes. Providers are more open to collaboration with other stakeholders, encourage patients to get more involved in their own care and equip them with knowledge and support required for fast recovery.
9. Virtual care
Musculoskeletal benefit solution must support digital-first model of care. The use of digital care for back and joint pain has multiple advantages. It is super convenient, and breaks down geographical barriers.
The digital care increases self-management and self efficacy and provides opportunity for employees to get more involved in the direction of their care. Much more so than with in-person care, digital MSK care includes a larger educational component. Because the clinicians are not physically present to assist with movements or joint stabilization, the onus is much more on the employee to learn these techniques and practice them continually.
Various studies have demonstrated that digital MSK care is more cost effective, is more engaging and have better outcomes than traditional in-person alternative.
In addition, virtual physical therapy focuses on using member-led active modalities that strengthen the body rather than passive modalities that only provide pain relief. Musculoskeletal benefit solution should provide technology tools that collects range of motion and other clinical measures remotely and automatically to provide clinicians the visibility into treatment compliance, and ability to customize the therapy plans – without scheduling a new visit. This leads to better adherence to therapy. Since they know their exercises are being tracked, members are more likely to follow their program.
10. Frictionless integration with in-person care
For employees who are best cared in physical settings, the digital MSK benefit solution must seamlessly provide the bridge to high-quality providers within the network. Unfortunately most in-person medical networks lack the ability to objectively quantify efficiency and quality of the provider.
The rating of a provider among peers should include both financial and quality metrics. Adjusting by risk is important because patient’s demographics, comorbidities and socioeconomic factors significantly impact the outcomes.
Lastly, this information should be available to clinicians for a warm hand-off from digital care to in-person care.
Sprite Health provides a digital-first destination to employees and their family members for all of their pain management needs. Leading employers choose Sprite Health to get better outcomes at lower cost – over 30% cost savings, reduction in unnecessary surgeries, opioid dependence, and absenteeism. In addition they provide their people an elevated experience with quick access to on-demand virtual care, evidence-based digital care programs for pain management, supported by our white-glove concierge service.