Is Digital MSK Lowering Costs of Care?

About Today's Edition

Before we started The Value Shift, we had produced a few introductory posts on hot topics in value-based specialty care. In fact, those posts became the motivation to create the newsletter.

One of those posts was our assessment of the Peterson Health Technology Institute's (PHTI) recent review of the clinical and cost-savings efficacy of digital musculoskeletal (MSK) programs. What's great about the report is that the PHTI is an independent, third-party organization that has a history of producing great, in-depth analyses of different digital health sectors.

We decided to do our own interpretation of the report's findings, with a special focus on identifying key factors that will help digital MSK programs achieve the clinical outcomes and cost-savings needed to justify continued use of, and investment in, these programs. This edition highlights the main points from our assessment.

To read our assessment in full, go to our website and check it out!

The Rise of Digital MSK

It is well known that MSK costs are too high because of frequency of unnecessary surgeries and procedures. This makes MSK care a modifiable condition. In fact, there have been several studies that link treatment patterns (e.g., likelihood of undergoing surgery) to an individual's zip code.

Because hospitals and providers are paid to do surgery, there is obviously an incentive towards action when it comes to the scalpel. This is a major misalignment with risk-bearing entities, such as health plans, employers, and certain provider groups, that are incentivized in the exact opposite behavior. This created a push towards preventative MSK technologies that can prevent individuals from seeking out specialty care (and therefore lower the likelihood of unnecessary surgery).

The earliest adopters of this technology were the self-insured employers, who are motivated not only by lowering costs of care, but also by providing high-quality wellness benefits that improve productivity, retention, and overall health.

The Many Flavors of Digital MSK

As more and more solutions started to pop up, it became obvious that there were key differences between them. The main types of solutions can be summarized as follows:

• Pure tech solutions: i..e, digital home exercise programs and without meaningful human intervention/oversight
• Coach-led solutions: digital exercise programs with health coach oversight.
• Physical therapist-led (PT-led) solutions: digital exercise programs with physical therapy oversight

In the Peterson report (we are excluding their review of remote therapeutic monitoring solutions in our assessment), those were the main differentiators. However, our personal view is that there are additional types of digital MSK care solutions, such as

• Virtual physical therapy: unlike the PT-led solutions, these are actually conducted by physical therapists through live treatment sessions, as opposed to simply oversight by a physical therapist. Think telehealth PT sessions during height of COVID.
• Clinician-led solutions: live, telehealth and digital health engagement by physician-led teams, often multidisciplinary, and with a central focus on exercise therapy/physical therapy.
• Virtual integrated practice units (IPUs): in these care delivery models (one example being Protera Health), multidisciplinary, physician-led teams use patient reported outcome measures (PROMs) and other quality tools to provide condition-based care as well as direct bridge to in-person treatment when necessary.

As seen above, there is a hierarchy of clinical intensity as solutions progress from tech-only solutions to those that are IPU models.

Like what you are reading so far? Check out our full assessment at our website!

PHTI Report Findings re: Clinical Efficacy

The PHTI report found that PT-led solutions were more effective than coach-led solutions, which makes perfectly good sense considering the concept of clinical intensity hierarchy above.

If you are considering implementation of a digital MSK solution, you are probably comparing multiple offerings, so it is safe to say that the most clinically effective option will be the one that is the most clinically rigorous.

PHTI Report Findings re: Cost Effectiveness

The report found that PT-led solutions, as opposed to coach-led solutions, were generally cost-effective, especially considering the increased expense of in-person PT analogs. Again, the report did not tease out cost effectiveness of higher intensity programs (physician-led or IPU), but it was consistent with the concept of increased efficacy that correlated to increased clinical intensity.

The report also explicitly stated that decrease in surgical intent was not a reliable indicator of cost savings. True cost savings are measured through decrease in healthcare utilization and/or through claims analysis.

Limitations of Current Solutions

The PHTI report listed out a number of key limitations in current digital MSK solutions. Most - if not all - stem from the fact that most solutions are vendors, and not providers. To highlight these differences:

Vendor solutions (most digital MSK companies)

• Provide wellness benefits and not clinical care
• Cannot contract in-network with insurance plans (see above) and can only be paid for directly. This means that doctors and other medical providers cannot prescribe the digital solution as a treatment, as they can only be provided as part of an employer or health plan benefit.
• Cannot prescribe medications, order imaging, or provide medical advice/evaluation/treatment

Provider solutions (e.g. Protera Health)

• Can act just like a physical therapy practice or medical practice
• Can contract in-network with insurance plans and be paid through claims as a medical expense (no direct contracting needed). This means that doctors and other medical providers can prescribe the digital solution as a treatment (which can then be paid for as normal through the individual's health insurance or out of pocket).
• Can prescribe medications, order imaging, and provider medical advice/evaluation/treatment

Understanding these differences will help explain why the limitations identified in the PHTI report are inherent to the nature of vendor solutions. These limitations prevent the full realization of clinical and cost-savings outcomes for most digital MSK solutions.

Limitations of current digital MSK solutions (note: given our recent introduction into the market, Protera Health was not included in the PHTI review)

• Lack of integration with clinical delivery (read: not available to medical providers for referral for their patients because not contracted with health insurance networks)
• Lack of integration with reimbursement infrastructure (read: not contracted in-network with health insurance)
• Lack of individualized treatment programs: most digital MSK solutions employ a "pathway" approach (e.g., low back pain) without customization to the individual. This is simply because of a lack of meaningful participation by licensed providers (PT, MD, etc) inherent in most tech-centered digital MSK solutions.
• Lack of risk-sharing with customers: most digital MSK companies get paid based on usage (i.e., achieving a minimum number of logins in a time period) rather than outcomes (clinical improvement, cost savings, etc).

What's Next for Digital MSK Solutions

Digital health solutions - fair or not - often come under more scrutiny than brick and mortar solutions, even though most digital solutions were created to reverse inefficiencies and deficiencies of traditional in-person health care.

To really provide the value that has been promised, digital MSK solutions must embrace the limitations identified in the PHTI report and provide services that address those limitations.

Technology in digital MSK has largely become a commodity (AI-driven and motion-capture technology for exercise therapy is fairly commonplace). What is not a commodity is actual delivery of high-quality clinical care that reduces unnecessary surgeries through both preventative treatment as well as lifestyle and behavior modification.

Digital solutions must also be viable for partners that are not self-insured employers, such as government health plan members (Medicare, Medicare Advantage, ACA, and even Medicaid). This requires solutions to be true clinical entities rather than simply a wellness benefit. It also requires solutions to rethink access, as many tech-centered products require broadband wireless access (which is certainly not universal).

How Protera Health is Ushering in the Future of Digital MSK

Protera Health helps health plans improve outcomes and lower costs of care for MSK conditions, especially in government health plan products. Our founding team of orthopedic surgeons and health plan leaders never set out to start a company; instead, we created the "magic wand" that we wished to give our patients, family, and friends that would ensure the highest quality care (virtual or in-person).

Unlike most MSK solutions, the Protera delivery model is a product of over a decade of real clinical transformation around PROMs, IPUs, and precision medicine implemented at leading healthcare systems around the country. We prioritized clinical and insurance contracting integration while taking financial risk on the quality of our outcomes. The best part is that we designed the program for 18 year olds, 85 year olds, and everyone in between.

To learn more, come visit us at our website.

To read our full assessment of the PHTI report, click here.

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