How to deliver high-quality musculoskeletal (MSK) benefits at lower cost?

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

Employer centric health 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).

Threshold Fee for Clinical Network

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.

5 ways a digital MSK solution can boost engagement & adherence

COVID-19 has not only changed where we work; it has also changed how we work. Hunching over a small laptop screen for a full working day, for days on end, is very different from doing a bit of work from home over a weekend. In a recent survey, 92 percent of chiropractors said that patients are reporting more neck pain, back pain or other musculoskeletal issues since the stay-at-home guidance began.

A majority of them are not looking to go to physical therapists or chiropractors to fix their problems. Reason – it is expensive and cost every time you go, only available in ‘office hours’ (not an option with kids at home) and risky because the virus is still out there.

It is not like it was much fun to go the clinic anyway. Traditional, in-person appointments are always difficult to fit into a normal workday schedule. For many people, it means an afternoon appointment. If you account for travel time and an hour-long visit, that person could lose two hours of his/her work day. Avoiding that scenario means scheduling an appointment before or after work hours, an option most clinics do not provide. Even when you are able to see the physical therapist or a chiropractor, most of them in traditional clinic setting are still following an outdated process. The therapist shows what exercises will help, give a printout of the exercise program. As soon as you get home, you forget most of it and those sticky figures on a photocopy of a photocopy is hard to understand.

It’s not surprising that up to 65% of people don’t fully adhere to their plans of care.

What is adherence to musculoskeletal (MSK) plan of care?

According to WHO definition, an exercise adherence is “the extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional.”

To be adherent

  1. The individuals should be exercising
  2. They should be completing the right # of reps and sets
  3. They should be following the correct techniques.

Why is adherence important?

Let’s start with the obvious. The exercise is beneficial for key clinical outcomes such as pain, physical function, and quality of life.

People who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function. The prescribed exercises for musculoskeletal conditions are targeted specifically at certain joints or muscle groups (depending upon the injury or surgery) and both options (not doing it at all or doing it incorrectly) lead to suboptimal clinical outcomes.

It does not help if the only way to get help is for you to drive to the clinic and see the therapist in-person.

What affects engagement and adherence?

Generally members are faulted for non-adherence, with reasons such as low motivation, pain, poor self-efficacy, and reduced social support. This is not entirely correct. Businesses don’t fault customers if customers are not getting value from their products. The same rationale applies to musculoskeletal care delivery. Lack of access, personalization, adequate guidance, motivation, reminders, reinforcement, psychological therapy and support from therapists are also big factors responsible for poor engagement and adherence to MSK plan of care. The traditional method of providing written information and activity monitoring in physical therapy is regularly completed via a paper handouts, which are often illegible, lost, forgotten about or generally confusing for members to understand.

In addition, outdated plan designs with deductibles and copays per visit create barriers for members when they want to get help.

An effective digital Musculoskeletal (MSK) solution fixes this problem.

A paradigm shift

An effective digital musculoskeletal (MSK) program shifts the control of the treatment from the therapist to the member, making them accountable as their own “therapist,” with the clinician acting as coach. This doesn’t mean that members are being left to get on with things on your own. Rather, the starting point is the individual member, their needs, ideas, goals and the premise that members can and do already have skills and resources to get better. The therapist’s role is to address beliefs that may hinder recovery and provide the member with the skills to successfully manage their musculoskeletal condition.

An effective digital musculoskeletal (MSK) solution is available anytime and anywhere. It assumes home environment as the default therapy setting, and builds the treatment framework that is member driven.

The knowledge, guidance, measurement and monitoring typically addressed in therapist’s clinic is brought to the member’s home. Instead of relying on physical interaction, the program promotes an active, non-invasive management approach involving the use of education, exercise, functional activity training, and behavioral and lifestyle changes. The member is considered an active participant in the recovery process and develops greater control in managing their condition.

An effective digital MSK solution uses a data-driven approach that incorporates features to increase engagement & adherence by using self-monitoring, guided problem solving, education & remotely monitoring adherence rates more objectively. This technology-enabled solution provides a collaborative environment in which the member and therapist work together to develop a member-preferred approach, including feedback and adjustment of the plan of care.

There are 5 adherence-boosting elements of an effective digital musculoskeletal solution, that delivers on better engagement and adherence. These elements are:

  1. Self monitoring and positive reinforcement
  2. Guided problem solving
  3. Tailored Education
  4. Remote Monitoring
  5. Provider Accountability

Self-monitoring and positive reinforcement

A data-driven digital musculoskeletal (MSK) system enables the therapists to provide virtual exercise prescription in a rich, engaging application instead of static paper handouts. Its intuitive app interface helps the member through her prescribed exercises, providing feedback and encouragement in real time.

The members are able to record the completion of their daily exercises, as well as provide their input to the coach. Activity monitors are provided to members that gives them real-time insights on their physical activity and exercise frequency. This helps them take control and become more accountable.

It has been demonstrated in multiple studies that members are more compliant when their therapist provides them with regular and positive feedback. Members who know they are performing the task correctly are more likely to be more engaged. The digital MSK system enables continuous feedback by the coach during the episode, instead of routine 1:1 virtual physical therapy sessions. This is delivered via asynchronous channels such as messaging in between sessions. Not only does it improve exercise techniques, it also act as a reinforcement to complete the exercises.

Guided problem solving

Various studies have demonstrated that members when prescribed 4 or more exercises had a lower rate of compliance than those prescribed 2 or fewer. This is common sense. Anyone who works a full time job or looks after a family does not have time for 8 exercises a day. More importantly is this actually necessary in order for them to get better?

An effective digital musculoskeletal (MSK) program is built on shared decision-making and guided problem-solving. It tailors physical therapy exercise program demands to the member. The goals are specific, measurable, action based, realistic and time framed.

The exercise plans involve gradual exposure to movements, positions, and activities that were once difficult to achieve. Members are introduced to regular exercises in small steps that they feel comfortable to manage, and guided to perform self-mobilization techniques and active exercise sequences to help manage symptoms. For example, in post-surgical rehab, the therapy is divided into multiple phases. The first phase starts immediately after surgery when the body part may be immobilized while pain and swelling subside. Then comes a series of progressively challenging exercises to restore range of motion, stability, and strength. The final goal is to return the patient to a pre-injury activity level. When therapists and members come together during 1:1 video sessions to reassess the symptoms, this approach providers member with evidence and reinforcement that a self-management approach is effective.

Tailored education

Tailored education is a core intervention for people with musculoskeletal (MSK) conditions. Members who are informed have more confidence in self-management practices, more likely to be active participants in their care and adhere to treatment.

Much more so than with traditional care, virtual models of care (supported in digital MSK solution) include a larger educational component. Because the therapist is not physically present to assist with movements or joint stabilization, the onus is much more on the member to learn these techniques and practice them continually.

Virtual physical therapy models place emphasis on the interaction between therapist and member. The live video environment on a smaller screen limits the distraction that members encounter and fosters communication and education between member and provider.

The education component includes a thorough explanation of the musculoskeletal condition, symptoms, mechanism, and management plan and involves teaching and counseling to modify behavior. Effective techniques include repetition, spacing of new information over multiple sessions, and limiting the quantity of material to important points.

Done properly, education bolster confidence and improves self-management, which leads to higher adherence to plan of care.

Remote monitoring

In the traditional in-person setting, the self-assessment of daily activity by members own assessment can be highly variable and subjective. An effective digital musculoskeletal (MSK) system uses an automatic monitoring system that provides an objective measure for adherence.

The virtual musculoskeletal system collects range of motion and other clinical measures and provides an intuitive dashboard to therapists for remote clinical review. If a member is off balance or moving incorrectly, the system provides feedback to the member and flag the issue for their therapist.

An oversight by therapists helps to ensure that members adhere to their prescribed physical therapy programs and complete their exercises safely and accurately. An effective digital MSK program enables both member and her therapist to see if the member performed physical therapy exercises correctly, how often exercises were performed, and how the member is responding to therapy. The therapist has the flexibility to customize exercises and help reinforce that prescription through an engaging experience.

Provider accountability

In the current system, the providers are not held accountable for quality, outcomes or cost. For example, despite demonstrated benefits of guideline-based care, only 54% of physical therapists provide care that aligns with recommendations. After the member visit, the provider provides a service, bill for that service and collect money for that service – regardless of the impact the service had on the member’s well-being.

Since the providers are paid irrespective of the result, they are not always motivated to increase member engagement and adherence to the plan of care. Most of them don’t have systems to track outcomes, nor are they equipped to track what happens outside their clinic.

An effective digital MSK program is accountable for cost and outcomes. It follows evidence-based guidelines to deliver care and measure the effectiveness of the program. It checks the compliance of all the interventions included in the program, care standards and introduce clinical audits as a part of the process, to identify areas in these standardized care processes for continuous quality improvement.

By offering transparent, bundled pricing for different treatments, an effective digital MSK provider is aligned to members and plan sponsors and work collaboratively with them to improve engagement and adherence.

Summary

A digital MSK solution is built to deliver care that truly address the specific needs of the member, while equipping them with the knowledge and skills they need to achieve long-­term success. To achieve higher engagement and adherence levels, an effective solution leverages self monitoring and positive reinforcement, guided problem solving, tailored education, remote monitoring and provider accountability.

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.

How to help employees find the correct path to musculoskeletal (MSK) treatment?

Imagine waking up with an acute back pain. Ask yourself what will you do, where will you go?

Some of us will turn to Dr. Google, some will call their Telehealth service, the lucky ones may be able to see their primary care physician on the same day. Not so lucky will go to ER.

Most recently available data suggests 37% visits for musculoskeletal (MSK) issues are made to primary care offices, compared with 31% to surgical specialists and 16.5% to medical specialists.

Essentially – the answer is all over the place. The pandemic is likely to have a big impact as well.

COVID-19 has not only changed where we work, but also how we work. In a recent survey, a significant percent of workers reported increased inactivity, insomnia, and alcohol consumption. People are hunching over their laptops in repurposed bedrooms and kitchen, which is causing a lot of them experience neck, shoulder or back pain. 3 out of 4 people with back pain stated that they have used internet to look for health information for themselves or their loved ones. We all know that online information is highly general and lacks context, creates more doubt and confusion over symptoms. This can lead to inaccurate self-diagnosis, inadequate advice and a prolonged treatment path.

MSK assessment and triage ensures that people with musculoskeletal (MSK) problems are directed to the right treatment in the right place at the right time. It provides clear, consistent and personalized information on prognosis, treatment options and self-management strategies to people with MSK conditions.

Fast access to right treatment options

Delays can be harmful to the member’s wellbeing whilst also adversely affecting the quality of care. Digital MSK assessment and triage reduces the timeline between someone deciding they need help and the time they receive clinical advice. It provides an online approach to finding the right care, and is accessible 24-hours a day; anytime, anywhere.

Digital MSK assessment uses a smart questionnaire which asks member specific questions related to their symptoms in an interactive discovery session. The tool picks up any worrying signs and symptoms more quickly and algorithmically analyze answers to identify the correct path to evidence-based treatments, in-app or in-person.

Because cost of treatment is a significant barrier to care in the US, it is important to combine suggested clinical pathway endpoints with cost-sharing data. This allows members get a side-by-side comparison of cost by providers for each suggested treatment. In some cases, where a self-management approach is appropriate it provides members access to tailored education resources and app-guided exercises, saving time and money.

Standardization of referrals to high-value care

Many muscle and joint problems can be successfully and safely self-managed without the need to see a health professional. The treatment guidelines for members at the initial stage of most musculoskeletal (MSK) conditions advocate that the diagnosis is based on history and physical examination rather than scans. Digital musculoskeletal (MSK) assessment helps in collecting information about patient history, needs and current symptoms to help clinicians perform better diagnosis and triage.

Digital approach to finding a correct path to treatment leads to standardized assessments and more consistent outcomes. When combined with network quality data, the triage helps in consistent treatment referrals to the recommended high-quality providers.

Cost Reduction

Getting members involved in their health results in best improvements in outcomes and cost savings. Members are often confused navigating multiple types of treatments before reaching the right course of action.

Where you start in the episode of care affects your outcome. The sub-optimal first-line treatment can be up to 25 times more expensive than the optimal option.

By guiding them to the right treatment options, digital MSK triage reduces waste on un-necessary, expensive imaging and treatments such as MRI, CT, Injections, surgeries etc.

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.