The Current State of Digital Health for Musculoskeletal Conditions: Findings and Opportunities as Reported by the Peterson Health Technology Institute

If you wake up one morning with searing low back pain and can’t feel your right leg, chances are that you will be more likely to go to an emergency room or call your doctor than log on to your employee benefits webpage to sign up for a health benefit.

To further guide the reader through the article, we have summarized the three main conclusions as follows:

To further guide the reader through the article, we have summarized the three main conclusions as follows:

1. According to the PHTI, digital MSK solutions are generally considered to be clinically and cost effective.
2. Solutions with actual clinical delivery, with oversight by a licensed physical therapist (at the minimum), are more effective than coaching/app-centered solutions.
3. There are significant limitations of current solutions that must be addressed to better capture the value of digital health for MSK conditions including more substantial clinical models, integration with traditional healthcare delivery and reimbursement, and willingness to take financial risk on outcomes (as opposed to usage).

Finally, we will provide an overview of what the next generation of digital MSK looks like, as designed by Protera Health, that addresses the limitations in first generation solutions.

Peterson Health Technology Institute

The Peterson Health Technology Institute (PHTI) is an independent non-profit organization established in 2024 by the Peterson Center on Healthcare. Its mission is to evaluate healthcare technologies independently to improve health outcomes and reduce costs.

PHTI assesses the clinical benefits and economic implications of digital health solutions, with a particular focus on their impact on health equity. The institute concentrates on technologies designed to enhance or replace traditional care models, including digital therapeutics, chronic care management apps, and remote patient monitoring solutions.¹

PHTI employs the Institute for Clinical and Economic Review (ICER) framework to evaluate these digital health technologies (Figure 1). ICER, also an independent non-profit, assesses medical evidence and facilitates public forums to help stakeholders understand and utilize evidence for improving patient care and managing healthcare costs.^1
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While venture funding for digital health products increased tenfold between 2012 and 2022, there is little to no independently performed research supporting the efficacy of many of these technologies.^2,3 This makes PHTI’s role in independently evaluating these technologies through the ICER-PHTI framework critically important. Of particular interest to this post is their recent, high-quality evaluation of virtual musculoskeletal (MSK) solutions.¹ It identifies the limitations of current (“Digital 1.0”) solutions and explores pathways to improving MSK care in the digital space.

Importance of Virtual Musculoskeletal Solutions

In a recent study in JAMA, it was found that MSK conditions – of the neck/back and of the other joints – are responsible for the highest costs of care to health insurance companies.⁴ Because half of the country gets their health insurance through their employer⁵, it is not surprising that self-insured employers have been aggressively seeking out cost-saving solutions for their MSK burden.

From a clinical perspective, the best way to lower MSK costs is through surgical avoidance and implementation of multidisciplinary treatment programs. In particular, early access to supervised physical therapy (PT) is a mainstay of preventative care.⁶ Research shows that patients whose MSK pain is treated by physical therapists, rather than medical providers, experience better functional outcomes, lower healthcare costs, and higher satisfaction.⁷ Unfortunately, up to 42% of people suffering from MSK conditions reported that in-person PT was too expensive,⁸ which contributes to the over-reliance on expensive tests, procedures, and surgeries (and thus on the continuously rising costs).

As risk-bearing organizations continue to feel the pain of rising MSK costs, there has been a rise in digital solutions attempting to lower the barrier to exercise therapy. These first-generation solutions can be broadly grouped as follows:

• App-based programs (with or without health coaching): web or smartphone applications that provide participants with a “DIY” home exercise program for a given condition (i.e., low back pain).
• PT-led programs: digital programs that include participation or oversight by a licensed physical therapist that can initiate and/or oversee a self-guided exercise program.
• Virtual clinical solutions: digital programs that provide virtual clinical care through MSK specialists, including physicians and physical therapists, with or without supporting technology.

Virtual MSK solutions offer a promising avenue to address these challenges by expanding access to care that improves pain and function. They are both convenient and efficient, allowing patients to receive treatment without leaving home or scheduling appointments, depending on the solution. Patients can complete their therapy at a time that fits their schedule, which is particularly beneficial for those with busy lives. Additionally, these solutions can enhance accessibility and patient compliance, as many feature reward-based mechanisms (e.g., badges, incentives) that encourage engagement. Finally, virtual MSK solutions have been shown to improve patient outcomes and reduce the need for unnecessary treatments, such as injections, medications, imaging, and surgeries.¹

Virtual MSK solutions have recently surged in popularity, which is unsurprising given that more than one-third of Americans experience MSK issues.⁹ These problems can significantly impact daily life by reducing quality of life, hindering productivity, imposing work restrictions (which can lower income), and driving up medical costs.¹⁰ In fact, MSK disorders are the leading cause of disability.¹¹ Physical therapists play a crucial role in managing MSK pain. However, these figures typically cover one evaluation and a total of eight visits.¹² This cost barrier may prevent patients from accessing the care they need.

From a broader perspective, the overall cost burden of MSK conditions is immense, totaling $380.9 billion in 2016.⁴ As the demand for MSK services rises—especially with the aging population—there is a pressing need for more affordable and accessible solutions.

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Digital 1.0 Solutions – Review of Evidence

The PHTI report performed an analysis of clinical efficacy and of cost savings for the different types of digital MSK solutions (Table 1).‍

Clinical Efficacy – the report found that, in general, solutions with physical therapist-led programs outperformed those with health coaching or an app-based exercise program as the main component. This makes intuitive sense, as the additional rigor of an exercise therapy specialist is likely to not only deliver better treatment to the participant but also be able to respond to lack of improvement that may be encountered. On the contrary, app-based programs, or those with health coaches as the primary oversight, lack the clinical knowledge required to successfully guide an individual through an exercise program, as well as to modify a program for the participant. It is important to note that, while most Digital 1.0 solutions do utilize physical therapists to help establish exercise programs, there is infrequent delivery of skilled virtual physical therapy (consisting of comprehensive history, physical examination, documentation, functional assessment, and prescribed tailored therapeutic exercises based on the examination).

Instead of true virtual physical therapy, some of these solutions incorporate motion capture technology to provide real-time feedback (both constant and immediate) as well as summary feedback at the end of a session, to help patients perform their home exercise programs (HEP). This feedback is delivered through wearable sensors or sensor-less computer vision (CV) technology.

While the concept of remotely monitoring a patient’s progress seems promising, these technologies generally have not been shown to be clinically valid or accurate.¹³ In particular, range of motion measurements using CV are often unreliable due to inaccurate detection of joint center locations and joint angles.¹⁴ This can affect the quality of care provided by physical therapists, as they may base decisions on faulty data. Additionally, poor feedback—whether given in a clinic or via motion capture technology—can negatively affect a patient’s movement patterns and technique, potentially leading to poorer short- and long-term outcomes.

Moreover, the motion capture systems used in Digital 1.0 Solutions typically rely on a motor control principle known as block practice (e.g., repeating similar exercises in specific sets/reps). While block practice can improve short-term performance, research shows that random practice—varying movements in terms of direction, position, surface, environment, and speed—leads to better long-term motor learning.^15,16 Therefore, even if a patient’s performance improves during their course of care with a digital solution (assuming the technology is accurate), a physical therapist cannot be confident that the patient has achieved the necessary motor skill acquisition and learning before being discharged. This is a crucial aspect of physical therapy that current Digital 1.0 Solutions cannot adequately address.
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Cost-Effectiveness – One of the most important aspects of the PHTI report was with regards to cost-effectiveness. The authors of the report acknowledged the economic impact of digital MSK solutions attributed to the “Decreases [in] net spending relative to in-person PT with savings from avoided care.” Moreover, the authors of the report indicated that the evidence “supports broader adoption,” which is a very encouraging finding that lends support to the notion that improved access to non-operative exercise therapy will lead to reduction in unnecessary procedures and surgeries.

The gold standard methodology for demonstrating cost savings would need to be established through a rigorous clinical study that examines the digital health solution impact on MSK costs (or possibly total cost of care). Because such a study would take many years to perform and analyze, digital health solutions have attempted to identify proxy data that could indicate potential for cost savings.

One such popular proxy is in the ability to decrease “intent” for undergoing surgery by the participant. The PHTI specifically called this out as an inaccurate method for measuring economic impact. Again, from a clinical perspective, patients often do not know if their injury or condition will require surgery; therefore, there is no economic value in measuring this variable. Instead, the acuity and severity of the symptoms are more likely to dictate whether or not someone has the intent to proceed with surgery but does not actually correlate with the need for surgery. For example, someone with an acutely herniated lumbar disc will no doubt think they need surgery, but after 4-6 weeks of rest, activity modification, anti-inflammatory treatment, and gradual return to activities, their symptoms would have largely subsided. Therefore, surgical intent has no role in measuring cost-effectiveness, as was clearly outlined in the PHTI report (Figure 2).
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Limitations of Digital 1.0 Solutions

While there is little doubt that digital MSK solutions improve access to exercise therapy for those who can access these solutions, there are still significant limitations that must be considered, all of which were identified in the PHTI report. They are as follows:

• Lack of clinical delivery integration: Because digital MSK solutions are delivered by vendor companies that must contract directly with the organization (i.e. with an employer), they can only deliver care for eligible members. However, only a small proportion of MSK care is delivered through employee benefits programs (<1%-5%), with most care still delivered through traditional healthcare channels (primary care, specialty care, direct access physical therapy, or urgent care/emergency rooms). For patients who seek initial MSK care through these routes, there is a significant likelihood that they will follow up (to the extent that they do) with the recommended treatments, whether it is in-person PT, medications (narcotic or anti-inflammatory), advanced imaging (e.g., MRI), or referral to a specialist (pain management, orthopedics, or spine).  Therefore, current digital solutions are not being accessed by the vast majority of individuals with MSK conditions, particularly those that need them most and who still use traditional healthcare channels for their care.
• Lack of reimbursement integration: Most Digital 1.0 MSK solutions are exclusively available as a wellness benefit and are not available through traditional health insurance contracting. To be reimbursable through insurance, the service provided must meet clinical standards (live, synchronous telehealth care delivered by licensed and credentialed professionals), documentation standards, and be submitted through traditional claims payment system.  However, most Digital 1.0 solutions are technology-heavy (see discussion above) and do not rely upon clinical care by specialists and physical therapists. Therefore, the bulk of services provided (health coaching, app access, motion capture, etc.) are not reimbursable by typical health insurance plans.
• Lack of individualized treatment programs – the PHTI reported that current solutions were limited by offering a “one pathway for all” with MSK conditions. The report did identify those solutions that were most clinically intense – such as with physician involvement – as being more readily available to provide tailored care solutions.  However, none of the solutions in the report were noted to provide truly precision-based care.
• Ability to assume financial risk – the PHTI report notes that most of the solutions tie payment to utilization milestones of the digital service (i.e., number of home sessions completed). While this payment infrastructure does ensure engagement with the service, it has no tie to actual outcomes, such as successful symptom resolution and/or avoidance of unnecessary procedures and surgeries.

The Future of Digital MSK: Multidisciplinary Precision Care

Digital 1.0 Solutions have truly paved the way for unlocking the potential of digital health for MSK care. The identified limitations have also outlined a roadmap to what the next generation (Digital MSK 2.0) should look like. These solutions should have the following key attributes:

• High-quality clinical care – real care, delivered by teams of clinicians, including MSK physicians, physical therapists, dietitians, and care coordinators, with the care supported by technology to drive engagement and education (as opposed to the other way around, which is a hallmark of many Digital 1.0 solutions).
• Integration with clinical delivery and reimbursement pathways – next-generation solutions should be able to be available to physicians and medical providers so that they can be prescribed for patients. Moreover, these solutions should be adaptable to not only direct contracting (as is done by Digital 1.0 solutions) but also to in-network contracting with health insurance plans. From a societal perspective, this will expand access to critical digital MSK care for not only individuals without such benefits from their employer but also to individuals who have such benefits but do not access them. Next-generation solutions should also be integrated into the documentation (electronic medical records) so that referring and affiliate medical providers can read progress notes from the virtual clinicians (which also means that the digital solution should produce these notes!).
• Precision treatment – each patient is different and should be treated according to their individualized needs. There are a variety of tools that can be used, in addition to clinician evaluation, towards creating such an individualized journey [i.e., patient reported outcome measures (PROMs)]. Digital solutions should be able to better provide precision treatment when compared to traditional providers that do not have the ability to infuse technology with clinical care.
• Commitment to risk-sharing – Risk-bearing organizations rely upon digital solutions to improve value-based care delivery, with the primary goal of improving outcomes and experience while decreasing costs. Therefore, digital solutions should be willing to place fees at risk in order to demonstrate true value, with improvement of health outcomes as a minimum objective.
• End-to-end care – Next-generation solutions should be able to guide a member or patient through the entire MSK journey, even if it means escalation to in-person services. Whereas current Digital 1.0 solutions often serve as “point solutions,” Digital 2.0 solutions must provide comprehensive care and/or coordination, so that the “right care is delivered at the right time.”

The Future of Digital MSK Care is Here: About Protera Health

Protera Health is a multidisciplinary virtual clinic that delivers precision MSK care centered on PROMs. The company was specifically designed to address the limitations of first-generation digital vendor MSK solutions.  Because Protera is a virtual clinic, treatment is delivered not only through in-network contracting but also integrated with healthcare provider workflows, thus reaching the overwhelming majority of individuals with MSK conditions (see Introduction section above!).  Additionally, Protera Health individualizes treatment according to PROMs, ensuring that the right care is delivered at the right time. Finally, Protera integrates within the partner organization for specialty care needs (i.e., specialty care and surgical treatment when necessary), thus minimizing leakage of services to external healthcare provider groups.  These key features directly address the limitations noted in the Peterson report.  

Founded as a joint venture with Henry Ford Health (Detroit, MI), Protera Health brings over a decade of clinical care transformation and cutting-edge scientific research into its clinical delivery model. More information can be found here.

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