Over utilization in back and joint pain care delivery

Musculoskeletal care delivery in the United States is highly fragmented. People with a musculoskeletal problem may go to a primary care physician, or get referred to a specialist but there is a spectrum to choose from, such as orthopedic surgeons, physical medicine and rehabilitation (physiatrist), sports physicians, rheumatologists, or other health professionals such as physical therapists, chiropractors or osteopaths. This fragmented model of care leads to significant over-utilization and waste.

For example, Only 1-5% of people with back pain have a problem that requires urgent treatment, yet 40-60% of people with back pain are sent for scanning – leading to massive waste.

U.S. surgical rates compared with other similar countries suggests that 50% of all orthopedic and spinal procedures are simply unnecessary.

Employees and dependents continue to go to specialists and ER for musculoskeletal services which can be more cost-effectively treated by physical therapy. Physical therapy within 14 days of the onset of pain minimizes the average total cost of care by 50%. Low back pain patients who receive physical therapy immediately after the pain begins and adhere to their treatment plan spend $3,000 a year in associated healthcare costs. Those who delay receiving physical therapy and do not adhere to their treatment plan spend $6,000 per year for all kinds of healthcare. 


This challenge provides an opportunity to the employer and health plans to redefine musculoskeletal care benefits based on predictable costs and specific outcomes.  A dynamic benefits design where easily accessible, low-intensity longitudinal conservative care is provided in a lower cost, high-value digital and virtual settings.

Dynamic benefit design for MSK care can be an innovative solution to maximizing health outcomes with the available health care budget.  The basic premise of dynamic benefit design is to align consumer incentives and payment strategies with value by reducing barriers to high-value health services. For example, you can choose to eliminate copays for physical therapy evaluation and treatment. This will help members to access physical therapy early and help you reduce expensive downstream surgeries and injections. Any additional costs for such incentives can be balanced by raising co-pays and/or co-insurance for using “unnecessary” ER visits for normal MSK issues.

Plan Metrics

Since the goals of the new model is to improve general MSK health and reduce total-cost-of-care, the outcome metrics should include-

  • Reduction in PMPM costs for specialist, ER, and Outpatient care.
  • Reduction in overall claim costs.
  • Improvement in health outcomes based on conditions managed in care plans. For example, how the average drop in pain levels for all members enrolled in chronic pain management programs.
  • Number of referrals managed.
  • Member engagement in their care plans.
  • # of same day/next day appointments

Sprite Health’s musculoskeletal benefit 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.