Issue 9, Sept. 2022

Back to the Future:

A look at the future of musculoskeletal treatment and what we need to do to get there.

In this latest issue of Leverage Insights, Leverage Health Executive Vice President, Mark Stryker is joined by Marcus Osborne, LHS’s Senior Healthcare Advisor and former Senior Vice President of Health Transformation at Walmart, to discuss the future of musculoskeletal care, and what the path to that future looks like for payers, providers and patients.

Our discussion kicked off with a dialogue covering several current issues within healthcare. We talked about the failure of traditional systems to diagnose people, the frequency of prescribed medicine and surgery compared to other therapy options, and the role of specialists in the quality and care mix. All these current challenges are relevant to musculoskeletal (MSK) disorders and care.

Mark: Marcus you and I can (and sometimes DO) talk about MSK care all day. There is so much to cover. MSK pain is an issue that affects pretty much everyone at some point in their lives. It has a big impact on health and quality of life for people – something for which I am the poster child.

Marcus: Musculoskeletal pain is an “everybody problem.” Even diabetes is a minority problem compared to the breadth of people every year who suffer from musculoskeletal pain. I’m not suggesting we shouldn’t address diabetes, just suggesting that musculoskeletal care is a big issue that impacts a lot of people.

Mark: And we can note the detrimental and accelerant impact that musculoskeletal issues have on diabetes and on many other chronic metabolic issues.

Marcus: Yes, there seems to be a correlation. People who are dealing with mobility issues, for which musculoskeletal pain is the leading cause, tend to also have other health issues. This can lead to depression, stress, and anxiety which then lead to other health complications.

Mark: It’s hard to be healthy and physically active when it hurts. As a recent knee replacement recipient, I can tell you that in the two years leading up to the procedure my health status was materially and directly impacted simply because my ability to be active went farther and farther down over time.

Marcus: That’s right. It makes you think that we could address some portion of the broad health issues and even some of the mental health crisis we’re facing in America by helping people to move more and have less pain. This is one of those core issues that everybody’s dealing with. Movement is fundamental in nature. When I was at Walmart, it was easy to get people to engage with you because you’re speaking about something they understand and relate to. I always said that there’s a reason why we can get people to come in and get dental care – because if your teeth hurt and you can’t eat, life’s not good. Similarly, you’ll come in and get your eyes checked because if you can’t see to drive or read, or watch TV, well life is miserable.

Part of the problem in the world of musculoskeletal pain is that it historically has simply not been as simple to either understand what is going on or know what to do about it and where to go for help.

People are motivated in miserable situations, but if you say, “Hey Mark, you should come in and get this annual physical,” you get a much different response. It’s important for health plans to understand an individual’s health so they can better support them. But many see annual physicals as a time-consuming, inconvenient, and uncomfortable nuisance. It’s difficult to see the benefit.

Mark: Why do you think MSK is such an ideal spot for intervention and dollar impact?

Marcus: It’s this perfect intersection for impacting tons of people in a very real way. It impacts hundreds of millions of people, so people care about it. If a care program translates into meaningful improvement in a person’s life, they will show up to participate. For example, if you are participating in a diabetes care management program and you are making progress and reversing your type two diabetes, you don’t feel the diabetes going away. You may lose a bit of weight, but it doesn’t manifest in the same obvious way. When you address MSK issues, you see and feel the improvements fairly quickly. The impact is much more immediately apparent. So, I think that’s what makes this space more interesting.

Now let’s look at the future where the problems are all solved. What does this ideal state look like?

Mark: So let’s think about this from the perfect end-state and work backwards. And let’s do that from the perspective of each person 1- finding care (and diagnosis) 2- getting care and 3- getting better.

Marcus how would you think about and describe that ideal future, both from the standpoint of the person and for the payer of the bills.

Marcus: I think about going to whoever is paying the bills for all the MSK care in the country, whether it’s an employer, whether it’s an insurance company, it doesn’t matter. Think about going to them and saying, “Hey, you spent $500 million last year on MSK spend. And your trend is going to be 10%. You give me that $500 million with no trend, and I’ll take care of all of it.” And depending on how good I am at those three critical elements you listed in your question, I might even be able to keep your cost below what you paid last year!

Mark: I agree with you, and to do something like that in health care would be groundbreaking, and the truth is, the tools already exist out there to do that today.

What does a groundbreaking solution mean to the people needing help and care?

Mark: Okay, so beyond just the dollars, what does a solution like that mean to the people needing help and care? Because if I am the MSK-partner you described then it’s my job to 1- let people know that I am there and how to get to me, 2- get them accurately and effectively diagnosed, 3- coordinate care and get these people where they need to be with all the associated measures around quality, outcomes, and experience, to ensure they get to the end of that musculoskeletal journey and say, “This was great. I am better off than I was before.”

Operationally: how you think about the big goal if you are the Payer? To have a partner who says, I can do all these things, I can save this money and I can give your patients, your members, your employees the absolute right experience, the absolute right outcome, and the absolute right diagnosis path to get them to the best outcome that they can achieve?

Marcus: That’s exactly right. I also think that the penultimate solution is one that results in a very different kind of care delivery pathway. I would argue that right now, I’ve got to have a lot of MSK pain to go do anything because it is so painful to go to my primary care physician. I believe we actually surveyed this specifically. We did survey it broadly, but we asked this question: “Describe for me your experience.” The most common narrative we heard from people went like this: “I don’t go to the primary care doctor [for an MSK issue] because I know they’re going to send me to the specialist. And I know the specialist is going to suggest meds and surgery. It’s not just that I don’t want to go to the primary care doctor because it’s a hassle, or because I know I will end up with a wrong or radical answer. It’s also the fact that they don’t ever have appointments available.” It really became about the person already having a defined expectation around how their care episode is going unfold, regardless of what the underlying physical issue may be or who they talk to about it.

Mark: This resonates a lot with me. My knee issue has been an over three-decade odyssey filled with different courses of physical therapy, surgery, injections – you name it. For the more conservative treatments (like PT) I felt like I was blocked at every turn because logistics were too complex with school / work / family, the course of treatment made the pain worse and the care givers weren’t listening to my feedback, or that when I tried to do it on my own it was simply not effective without some help and feedback.

In my day to day at Leverage Health I work with our portfolio company called RecoveryOne, which is a full-body digital physical therapy and MSK care platform. I became their patient too. I can honestly say that it is the only time in all of my history with MSK injuries that I can say that all of the barriers I mentioned earlier simply evaporated, and the difference it’s made in my current recovery is simply tremendous.

Marcus: Exactly. For where you were previously, it’s the actual knowledge of what’s likely to come next that people anticipate. It’s a little bit how people think about car repairs. I may think my car has a little problem, but it’s going to have to have a serious problem for me to take it to the mechanic because I know the mechanic’s going to come back and tell me it will be $700, at least regardless of the underlying issue. Right? Until I feel like that $700 “pain threshold” has been met, I’m not showing up. In the MSK scenario, you could do the diagnostics more conveniently than going to primary care. Think about what RecoveryOne is doing. If somebody has an MSK issue, we can immediately help them understand “What’s wrong,” and “What do I do about it”, and then move them into a virtual PT environment.

Post evaluation, these activities become much more frictionless in the context of the patient experience. I think that results in a very different pathway where people get their specific care faster, cheaper, in a simpler, more streamlined way.

Mark: Right – There’s no doubt this type of “process” work has been done in other sectors.

Marcus: We can look to the auto industry for a great example. Today, the average vehicle is on the road in America twice as long today as it was 30 years ago. They believe the fundamental two reasons are: 1) the advancement in sensor technology on the vehicle and 2) was the rise of a new care modality mode that we now know as Jiffy Lube. Jiffy Lube enables American consumers to say, “Oh, I don’t have to go to the mechanic. I can literally roll in on my own time, pay 30 bucks, get all my maintenance work done, get a 40-point check on my car, and then I’m out!” They may tell you there are issues that you may want to address but it lets you decide when and where you do that.

It’s a very different model. So, guess what? People follow through on those recommendations more today than they did in the past, therefore their vehicles are healthier. Right? And you know, we didn’t put more wheels on the car. The engines are functionally the same, and nothing else really changed. I think there’s a parallel story where you can start to see employers that are moving to PT First. You can start to think about retailers introducing some of the more frictionless programs that are changing the dynamic and moving us toward better outcomes.

Where We Are Today

Mark: So, let’s think about where we are today, and what actionable steps are available to start moving us toward the end-state we talked about earlier. I think a big step is directing people to care providers who are delivering conservative diagnostic approaches that are data driven and integrated with analytics.

Marcus: Absolutely, yes. And something that is eminently achievable today.

Mark: An adjunct to that is Payers allowing these partners to start taking risk and guaranteeing financial outcomes – even if the scope is narrow at first. These care partners would need to be data-driven to enable cohesive sharing of data all the way from the time of diagnosis, through the time of treatment, and to any additive or differential care points along the journey, as they might get elevated to a specialist or redirected in some manner. Does that sound like a middle step to you?

Marcus: Yes, it does. Only half joking, I think the other middle step is that in about three years all your care is now coming from Amazon. I’ve now responded to a number of reporters on it who have suggested it’s not a very good idea. I simply respond, “Best freaking deal I have ever seen. They just threw down the gauntlet.” Seriously, with the speed at which that end of the market is moving people need to be looking at things like RecoveryOne and others all up and down the MSK care spectrum that can move them forward, otherwise they may simply end up looking like they are standing still.

I think your story is a good one. Even though I’m using the Amazon example jokingly, in some ways, the rise of those groups stepping more aggressively into those models reinforces everything you say. Because that’s exactly what they want to do. They will use data driven analytic approaches to guide how care is delivered.

Mark: So to get everyone moving in the right direction: Start with conservative approaches at the beginning with care partners who are willing to put their balance sheet where their care is, even if it is limited at first: even though they might be a little bit siloed, and it might be focused on vendor partners in the near term and finding the right ones. Find the right vendor partners that can share data with you. Maybe they can take a little bit of risk if they’re set up right. And over and above everything, make sure that the people you’re paying the bills for, whether it’s your employees or your members, are getting the right experience.

Marcus: I think that is right. Just those small steps could totally reshape MSK care and cost for a lot of people.

Conclusion

As MSK care continues to evolve, we’ll likely experience iterations that represent progress in the movement toward more frictionless care options. Because it is so prevalent and relevant to so many, MSK care will likely lead the way in transforming health care processes. The changes will impact all stakeholders but will definitively improve the patient experience and result in better, more rapid outcomes overall.