Half of members enrolled on
Why so costly? As many as 80% of MSK conditions are wear-and-tear cases like rotator cuff tears and meniscal degeneration that often receive diagnostic imaging like MRIs and CTs, the results of which funnel patients into costlier surgical solutions — sometimes up to $200,000 per surgery. With our aging population, if self-insured employers don't find a first line of defense solution, surgery rates will continue to increase.
Emerging research shows imaging resulting in surgery isn't likely to eliminate pain. About 90% of surgeries for chronic pain aren't supported by adequate evidence, the result being no more effective than doing nothing. Therefore, most surgical patients remain in pain, requiring subsequent surgeries.
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Another point to consider is how this affects a patient's mental health, which can exacerbate physical pain. For example, diagnoses like depression or anxiety can result in 66% higher claims in low back pain and other cases.
Bear in mind that while MSK aging is common and normal, like graying hair, pain is not. Using arthritis as an example, when treated with physical therapy, patients often feel pain relief within two weeks of consistent treatment. Imaging leading to surgical solutions may result in patients having unnecessary surgery for something that wasn't causing the pain in the first place.
If imaging results don't validate pain, what does? Modern science suggests that causes of pain, especially when chronic, are not a result of tissue damage. It's a complex experience affected by our beliefs, sleep, mood, social health and movement habits — much like a headache that manifests when a few of those categories go awry. This is why it is common for one cortisone injection to lead to another, and ultimately to surgery. Injections cover up symptoms, but they don't address the root cause. All the while, insurance is covering surgeries that aren't likely to address the patient's pain.
I ask myself, why should plan sponsors pay for surgeries that cost tens of thousands of dollars and put plan members under the knife if they don't even do what the member is hoping for, which is relieving their pain? Research indicates that surgery shouldn't be the first stop for a plan member in pain, even if it's historically been expected.
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To help employers be responsible fiduciaries and thoughtful payers, we don't want them to pay for unnecessary surgeries that can hurt members. That's why benefit advisers should encourage their clients to embrace meaningful upstream solutions to treating MSK conditions beyond direct contracts with imaging and surgery centers of excellence.
One such example is Aware Health, which developed a way to leverage algorithms to bring typical imaging frequency rates down 83% without missing a serious condition. The company's growing data shows they are helping members with wear-and-tear conditions who initially intend to get surgery to avoid surgical intervention 95% of the time.
This is reducing self-insured payers' MSK spend by more than half, saving the plan up to 10% in overall healthcare spend even within the first year. With an average of 24% engagement for members who see a virtual doctor of physical therapy for at least one ailment, about half return later to the company's platform for other areas of pain.
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Is avoiding surgery just kicking the inevitable down the road? Members of these avoided cases so far are reporting high satisfaction and meeting their pain goals. Laureen Strohl, a benefits director and Aware client, notes that a concierge MSK service helps employees not only save time, reduce pain and fast-track their recovery, but also save money.
Sometimes surgery is necessary. Everyone can agree on that. In specific cases, imaging is needed to rule out serious underlying conditions, but that is less than 1% of the time. Can a plan help members avoid unnecessary surgeries? We're helping plan sponsors do just that.
So, are your clients paying to keep their health plan members in pain by sending them through an insurance carrier to diagnose their pain with imaging and treat with surgery? Maybe because they believe the status quo is easy, or the physician thinks it's best. It may be because hospital systems get reimbursed well for doing these procedures, the fox guarding the hen house. But there are alternative solutions now that will improve outcomes and reduce costs.
