The rise of musculoskeletal care and how managing it is changing

Richard Valdesuso, MD, medical director of the AIM Musculoskeletal Solution

There is no shortage in reports about the rising incidence of musculoskeletal disorders and, likewise, the rising use of orthopedic interventions, like spine surgeries, joint replacement, and pain management.

Richard Valdesuso, MD, medical director of the AIM Musculoskeletal Solution, sat down to discuss the surge of this type of care, the value of “boots on the ground” provider engagement, and the “integrated” future of managing musculoskeletal care.

For many health plans, musculoskeletal disorders is one of the top three costliest disease categories to treat. What’s the reason for this magnitude of spending?

It’s really not a single reason, but many, driven by both members and physicians. Let’s start with members.

We’re seeing more joint surgeries largely because of “wear and tear” among certain populations. Baby boomers used to an active lifestyle are increasingly seeking out services, like surgery. “Weekend warriors” want to get back on the road as soon as possible after injuries. And youth are involved in more intensive, year-round sports and training, leading to arthritis at an earlier age.

And we can’t neglect obesity: The number of obese Americans is dangerously high, and research has told us for some time that obesity drives musculoskeletal pain and, consequently, musculoskeletal care.

Physicians are also driving some of the increase in cost. Many physicians coming out of training today are eager to try new technologies and minimally invasive techniques on patients whom in the past would not have been a candidate for surgery. As a result, the threshold for surgery, especially spine surgeries, is dropping. Providers are pushing to complete these cases in ambulatory settings, where it’s convenient, affordable, and, as a result, more attractive to health plan members.

Finally, the opioid crisis is playing a role. Providers are turning to interventional pain management procedures because in many cases, it’s a safer way to manage certain chronic pain syndromes.

What often precedes plans’ decision to partner with a company to manage care more vigilantly, says Dr. Valdesuso, is a simple question—”Do our providers overprescribe procedures more than plans in similar regions?”

With all these forces at play, at what point do health plans consider looking for a partner to help them ensure clinically appropriate, affordable care for their members?

What I hear most often from plans who end up choosing a partner like AIM is that they asked themselves a simple question: What would the quality and affordability of care for our members be like if managed more comprehensively?

They also typically want to know how they compare with their peers: Do our providers overprescribe this surgery and that surgery more than a plan in a similar region?

When the plan starts to ask itself those questions, it’s probably a sign that they’re ready.

So a health plan selects a partner. What happens next?

In short, extensive planning with the health plan and ample collaboration and coordination with their providers.

And once the solution’s in place, benefits take on a domino effect. Members begin to receive more appropriate musculoskeletal care, which tends to be less expensive, so the plan more easily hits its medical loss ratio (MLR) goal. And by hitting its MLR objective, the plan can reduce members’ premiums and out-of-pocket spend, which are major factors in member satisfaction.

You were a practicing orthopedic surgeon for more than 20 years, so you understand the provider experience intimately. Imagine you were still practicing: If a health plan notified you about their new solution, how would you want them to get you involved?

My experience with health plans would have been vastly different if I had the opportunity to collaborate with them the way that we’re working together now. The partnerships between us, plans, and providers are such an intuitive, meaningful part of the process. And I’m certainly biased, but the way AIM does it is just fantastic.

How so?

We take a “boots on the ground” approach, as we say at AIM. Before the solution goes live, our provider engagement team and I visit with providers and their office staff to lead training and offer the opportunity for providers to ask questions. We work diligently with the providers to make sure that these trainings accommodate their schedules rather than interfere with them.

For larger or complex provider groups, we can assign a member of our clinical team to help them navigate the solution and assist with onboarding. It’s an important part of our provider collaboration model.

So do away with provider-training dinners?

[Laughs] Every doctor loves a good dinner, myself included. But, in my opinion, we can engage providers and their staff in a way that’s more convenient for them and more affordable for health plans.

The topic that interests providers most—how AIM develops its evidence-based clinical appropriateness guidelines, according to Dr. Valdesuso.

When you go out and meet with providers, what questions do they ask most often?

Providers are very interested in our guidelines and the efficiency of our platform. For example, just recently, our provider engagement team and I visited a client. The providers that joined us that day asked a lot of insightful questions demonstrating how committed they are to the practice of evidence-based medicine and best practices. They wanted to know why we arrived at certain guidelines.

And how do you respond to those types of questions?

Ultimately, my responses are straight-forward, because, one, we base our clinical guidelines on clinical evidence, and, two, we have one of the most rigorous, if not the most rigorous, guideline development processes in the industry.

And the physicians that I’ve met appreciate that candidness. They recognize the shared commitment to clinically appropriate care, and they value the transparency, which they may not have with other partners.

We’ve touched on the provider experience, but how does managing musculoskeletal care affect the member experience?

There are really two benefits that members gain—clinically appropriate care and engagement. I’ll use a common member case to fully demonstrate the experience.

Let’s say one of your members is in her early 60s. She’s been experiencing back pain while standing for some time, and it’s so bad that she walks hunched over. Her physician diagnoses her with lumbar spinal stenosis and orders spinal fusion surgery. That procedure in my hometown of Chicago can cost more than $120,000.

Our solution reviews the order for the fusion against clinical criteria and, for this particular member, finds that fusion is not the best intervention for her. So, the member’s physician and one of our physicians consult, and the member’s physician learns that actually, according to evidence, a simpler procedure—decompression—meets her clinical needs.

For the member, that means she undergoes a much less invasive surgery, takes less time off work to recover, and saves a considerable amount on her out-of-pocket spend.

Dr. Valdesuso sees a common thread in the future of ensuring appropriate musculoskeletal care for members—integration.

What does the future of managing musculoskeletal care look like?

Integrated. That’s the theme that will emerge, I think. The future will entail predictive modeling that brings together different data, integrating prior authorization into the EMR (which AIM already does for advanced imaging with AIM Inform), and managing the continuum of care by condition, like back pain. With the AIM Radiology Solution, our Musculoskeletal Solution, and new solutions in the works, that future isn’t in the distance—it’s already on the roadmap.

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