September 28, 2022

Every year, about half of all adults in the United States experience back, neck, shoulder or other musculoskeletal (MSK) pain.¹ According to Business Group on Health’s 2023 Large Employers’ Health Care Strategy and Plan Design Survey, over the last 3 years, surveyed employers ranked MSK conditions as one of the top two conditions driving their health care costs. In addition to the direct health care costs, MSK conditions have a material impact on employee productivity and well-being. People living with MSK pain missed 8.2 days of work in the past year, and those with both MSK pain and mental health needs missed 13 days.²

MSK conditions are often accompanied by chronic pain as well as limited mobility and dexterity, with low back pain being the single leading cause of disability in 160 countries.³ The impact of these physical limitations is leading to early retirement from work, lower levels of well-being and reduced ability to participate in society.³

Patients suffering from MSK conditions tend to be more likely to opt for an aggressive treatment to relieve their pain and mobility discomfort, which can result in high rates of inappropriate surgeries and use of opioids. Appropriate management of MSK pain, which centers on addressing its causes, may include rounds of physical therapy (PT), in addition to pain medications and/or other pain management techniques.

PT is often considered the best first line of defense for MSK issues. Besides improving mobility, it can significantly reduce chronic pain and prevent unnecessary medical procedures such as joint replacements and surgeries.⁴ Unfortunately, PT services can be inconvenient, time-consuming and costly, which in turn can affect patient adherence: Less than 25% of those who do initiate PT actually complete the prescribed course of care.⁵ Maintaining adherence to PT regimens remains a challenge for many (particularly for lower-income and rural patient populations) due to the burden of multiple in-person visits, which often are scheduled during workdays. For some patients, out-of-pocket costs and coverage limits may also create a barrier to completing ongoing therapy visits.

The pandemic sparked a shift in how and where employees work, but a potential consequence is that employees may now spend more time working in environments that are less than ideal with respect to ergonomics. This, along with cost and adherence concerns, has led to virtual MSK solutions emerging as a key area of interest for employers. This article summarizes emerging trends and considerations for employers looking to implement virtual solutions within the MSK space.

What Are Musculoskeletal Conditions?

MSK conditions consist of more than 150 various diseases/conditions that affect the locomotor system, impairing muscles, bones, joints and associated tissues such as tendons and ligaments.³ They range from conditions with an acute onset, such as fractures, to lifelong conditions associated with ongoing pain and disability.³

Examples of MSK conditions include, but are not limited to, the following:

The economic and health care impacts are far-reaching and significant: MSK conditions make up 19% of all health care visits, and the cost for treatment and lost wages each year totals $980 billion in the U.S.⁶ Approximately 1.7 billion people around the world live with MSK conditions.³ Moreover, MSK-related conditions are one of the main factors driving individual employee absenteeism.⁷ In the U.S., work-related MSK disorders make up about 40% of all workplace injuries resulting in lost time.⁷

Chronic pain management due to MSK conditions also drives direct medical and pharmacy costs and often culminates in surgical interventions to address the specific source of pain for the patient.⁸ To help members avoid unnecessary surgeries and positively impact long-term health outcomes related to MSK, it is important to engage members in appropriate interventions and program participation early in the care journey.

Many employers have adjusted their plan design to address the overutilization of surgical interventions for MSK conditions. These strategies may include prior authorization requirements for joint and back surgeries as well as mandated second-opinion or decision-support programs. When surgery is deemed necessary, employers may implement Centers of Excellence (COEs) arrangements to ensure that their members receive care from high-performing providers and health systems. Recent data suggest a growing interest in COEs, with 52% of surveyed large employers offering COEs for MSK conditions/procedures today, and another 17% considering doing so by 2025.⁹

Virtual MSK Solution Landscape

The demand for physical therapists has long outpaced supply, particularly for employees and their families living in rural communities facing more barriers to access in-person care.¹⁰ Due to both limited physical mobility for those suffering from MSK conditions (which may make it more difficult for patients to travel to in-person visits) and long wait times (which may stifle patient adherence to PT treatment regimens), some employers have identified the need for additional points of access to MSK care. Employers surveyed indicated that these programs are becoming an expectation of a comprehensive benefits practice: In 2023, 58% of respondents will offer virtual MSK care management/PT to employees, and the field is positioned for growth, as 80% of respondents will offer or are considering offering virtual MSK treatments in 2024/2025.⁹

Cost and inconvenience are the barriers cited most often to adhering to PT treatment regimens. While telehealth can provide great value to both patients and providers, providing an end-to-end experience, including in-person follow-up as necessary and considering patient preferences in the type of care they respond to best is essential. Though more longer-term outcomes-based research is needed to assess the value and efficacy of digitally enhanced PT, one study notes a lower total cost of care in the short term and similar patient-reported outcomes among patients who transitioned to telehealth compared to those who had only in-person PT visits following hip surgery.¹¹

Virtual MSK/PT platforms currently available in the market are generally differentiated by the features listed in Table 1.

Table 1: Features of Platforms for MSK Conditions and PT

	Traditional PT Platforms	Digitally Enhanced PT	Fully Digital PT	Digitally Guided "On Demand" Exercise Programs
"In-person" Component	Yes: All PT visits completed in-person	Yes: Motion-based PT in combination with in-person interactions	No: Virtual PT-led exercise program	No: Virtual exercise therapy program
Level of Clinical Certification	Licensed physical therapists	Licensed physical therapists	Licensed physical therapists	Health coaches and/or physical Therapists
Required Technology for Patient	None	Smartphone/tablet	Smartphone/tablet Wearable sensors	Smartphone/tablet Wearable sensors

Key Factors to Consider When Choosing Virtual MSK/PT Solutions

The questions listed below are a good starting point when assessing whether a virtual MSK/PT solution is right for your employee population.

• Is there a need that is not currently met by an existing in-person PT network? Employers should investigate whether their carrier’s network is adequate with respect to access for their employee population’s needs. Are there any gaps in access that can be identified through out-of-network claims in specific geographic areas or among certain demographics?
• Can convenience be solved through technology? In recent years, there have been numerous advances in technology that have made care more convenient and engaging for patients. When surveyed, health care consumers found virtual visits more convenient relative to in-person because they didn’t have to leave their home (41%) and cover transportation costs (37%), and they also saved time (37%).¹² From the provider perspective, increasing convenience leads to better patient engagement: A majority of surveyed providers believe that virtual visits made patients more likely to make and keep their appointments.¹² In addition, virtual care may ease physical access barriers, especially mobility barriers (e.g., often people needing PT cannot drive and may need to arrange for transportation). As technological capability continues to evolve in the virtual MSK/PT space, employers have an opportunity to leverage emerging advancements to improve convenience for patients to further increase compliance.
• Which conditions prevail in the target population? Some virtual PT vendors offer a full scope of clinical services, including post-surgical therapy, whereas others focus on a group of patients with mild or moderate joint pain and early interventions that do not require a licensed physician. When deciding on the most appropriate program to meet employee needs, employers should evaluate their workforce (e.g., determine risk factors for different job roles within the employee population, segment and analyze by zip code to identify employees benefiting from alternative care) and conduct claims analyses with an eye for risk indicators, such as painkiller prescriptions, mental health diagnoses, provider interactions due to MSK pain or others that can identify the need and target population.
• How will you pay for this service? Will there be employee cost sharing? Some vendors bill for virtual PT through the medical plan similar to how they would for in-person visits, whereas others charge a fee directly to the employer for services more likely to be offered as a well-being program that is free to participants and not subject to cost sharing. For services billed through medical claims, employers should discuss with their carriers the level of reimbursement they are willing to consider for virtual PT and whether, based on expected value and outcomes of such therapy, they should be billed at the same rate as for in-person visits.
• What technology is required to use the program? Some solutions require a tablet along with sensors to be sent to the home by the vendor, while others can track movements through the camera in a smartphone. For solutions requiring specific equipment (e.g., vendor-specific tablet, sensors, etc.), it is important to consider the incremental cost of device rollout to employees. On the other hand, not everyone has the technology to be able to run the program on their own devices. Ensure that a high enough percentage of the target population has the required internet access at home to adhere to the solution. Consider including the equipment needed for the solution at on-site clinics if feasible.
• What should be the providers’ level of clinical certification? Some providers use health coaches while others deploy licensed clinical physical therapists. Using licensed clinicians can be more expensive but allows for a broader range of services to be offered.
• How will you drive engagement in the solution? How a virtual PT/MSK program is positioned (well-being vs. medical/clinical benefit) can have implications on overall engagement and utilization. While virtual PT programs offered through well-being platforms may not be able to offer a full scope of clinical services, they can be utilized as an excellent entry point for virtual PT. Consider engaging with care management and navigator teams to further target communications and outreach.
• How will data be shared between the vendor and your health plan? Ideally, any strategy for addressing patient needs should be data-driven. Some employers may choose to tactfully leverage data and analytical tools offered through their vendor partners to gauge employee utilization and engagement. However, timely and actionable data sharing among health plans and vendors remains a challenge.
• How will the program’s performance be measured? Quantifying reductions in pain scores or other discrete mobility improvement outcomes, prescription drug utilization and avoided surgeries can be monitored as performance measures. Determine how the solution gathers feedback from participants, as patient satisfaction and member experience measures can also help employers determine the efficacy and success of a given program.

   

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