A New Model for Non-Operative Orthopedic Care

BY LANG ASTON

“The more things change, the more they stay the same.” The French writer Jean-Baptiste Alphonse Karr had it right, at least as far as orthopedic care is concerned. Most people would argue that the U.S. has the most advanced medical system in the world, and our approach to orthopedic care specifically is widely lauded as exemplary.

Technological advancements have improved recovery time and outcomes, while the trend from inpatient to less expensive outpatient settings has continued to lower costs and improve patient access. Yet with these improvements, musculoskeletal care remains the most expensive and fastest growing segment of our U.S. healthcare system, fueled by a growing demand from an aging and more sedentary population. In a new era of value-based healthcare, maybe it’s a good time to step back and ask ourselves, “Is this working?”

According to JAMA, musculoskeletal conditions cost the U.S. 1 over $400 billion annually, or 10% of all healthcare spending. That is more than cancer or cardiovascular disease. Lower back pain is one of the top reasons people crowd primary care offices or emergency rooms. Medications (e.g., opioids) and injections are often the tool of choice for many looking for a quick way for the pain to go away.

Other patients are sent on to receive unnecessary imaging scans or see specialists without first seeking more conservative and cheaper treatments. And with the proliferation of digital healthcare, dozens of new companies are selling the promise that musculoskeletal telehealth will provide a suitable replacement for in-person care.

In short, while we have come a long way to improve procedures and reduce surgery complications, we have only poured fuel on the fire of runaway orthopedic spending—with no measurable return on investment. The opportunity to embrace a value-based world is there—if only we can push away from the dock.

PUTTING THE PATIENT LAST

The current system is not broken; it is working just as it was designed. The scenario plays out every day in the U.S. You hurt your back lifting too many weights at the gym, and you can’t walk the next day. You call your primary care doctor, who sees you in the office and tells you to get an MRI. You are prescribed some medication to take the edge off until you can get back to walking upright again.

Meanwhile, after weeks of waiting, you get an MRI and are told not only do you have a ruptured disc, but you also have degenerative disc disease and should go see an orthopedic surgeon. You are referred to a pain management physician for steroid injections. Frustrated from lack of improvement, you go to a surgeon and are told you should have surgery to fix the disc problem.

As a patient, you question whether that is the best solution, but no one is there to provide guidance, so you get back on the internet for more research. You discover that your employer has an orthopedic benefit with a wearable device for your low back pain, and you spend frustratingly long hours trying to figure out if you are doing your exercises correctly.

Unfortunately, this is a true story and one of millions annually that painfully illustrate how our system is too fragmented, siloed, expensive, and misaligned, and puts the patient last. In a fee-for-service world that rewards volume over value, it’s not the system that is broken—it’s the design.

A DIFFERENT WAY FORWARD

Over the past year, the healthcare system was forced to move online as the pandemic made it possible to seek care without crowding waiting rooms. Fee-for-service volumes for elective procedures decreased significantly for a few months, and providers filled the void with telehealth visits and digital solutions to provide safe access to care for patients. But interestingly, waiting rooms started filling up again once pandemic infection rates began to decline.

As the healthcare industry has embraced the path to value, the time for non-operative orthopedic care management has arrived.

Patients are seeking connection and are suffering from not only pain, but also from depression and anxiety in unprecedented numbers. Digital health is clearly here to stay, but there is no substitute for an in-person provider visit. As someone who had a ruptured L2/L3 disc, I can tell you firsthand that a telehealth visit with a wearable chest strap was not an option for me to assuage my pain and anxiety. Perhaps things do remain the same—maybe the need for human connection will continue to be paramount to create an environment in which to heal.

But while the world adjusts back to some equilibrium of online and on-site care, the rules of the game have changed. Alternative payment models are accelerating in all areas of medicine, including orthopedic care. Changing the game are risk-based medical groups, integrated health systems, and payers (including Medicare), which are rapidly adopting new models that create better alignment for risk-based payments.

And perhaps most importantly, patients have changed how they consume and expect value from the healthcare system—engagement, connection, wellness, convenience, and access. All of these elements will be critical for the orthopedic industry to address.

But somehow, orthopedic care has been slow to adopt this approach—perhaps due to a legacy system built on lucrative fee-for-service procedures and physician consolidation to protect the status quo. Maybe the promise of digitized physical therapy solutions will fall short of addressing the complexity or chronicity of 80% of musculoskeletal (MSK) spending. Maybe there are too many patients in surgeon waiting rooms who don’t need surgery.

Perhaps now there is a different and more impactful way forward to target real outcomes and savings for people suffering from chronic pain and for those providers and payers who want a winning strategy in a value-based environment. So with all the moving pieces to realign the value chain in orthopedic care, what will be a vital component? Introducing non-operative orthopedic care management.

AN INTEGRATED CARE MODEL

What does non-operative orthopedic care management look like? Imagine a new care model that is focused on MSK health—not purely treatment—and that puts the patient first. Now imagine that this model:

• Matches a patient with a personal coach to customize treatment before, during, and after an acute episode occurs—and refers to downstream care delivery only if and when it is needed

• Offers a full range of integrated programs—including nutrition, mindfulness, addiction services, and sleep counseling—to address the complicated physical and behavioral factors that lead to chronic pain

• Features a care team composed of orthopedic surgeons, physical therapists, addiction specialists, sleep counselors, mindfulness professionals, and nutritionists working together to understand and address the unique underlying issues impacting pain for a patient, without a singular focus on performing surgery or injections

• Provides synchronous and asynchronous access to efficient and personalized care, both on-site and online, to meet the patient where it is most convenient and impactful

• Integrates with orthopedic surgeons and primary care physicians to remove the burden of chronic pain sufferers from their waiting rooms and allows surgeons to see only patients who really need surgery

• Unveils our body’s magnificent ability to heal itself without any invasive procedures, opioids, or surgery

• Leverages artificial intelligence to enable a scalable population health solution to take financial risk for total cost of care

• Offers a maintenance program customized to address sustainable orthopedic health with access to education, exercises, nutrition, and community support

As the healthcare industry has embraced the path to value, the time for non-operative orthopedic care has arrived. Indeed, perhaps it is time for a change. o

Lang Aston is Chief Growth Officer for SpineZone.

Reference:

1Dieleman, JL, et al. US healthcare spending by payer and health condition, 1996-2016. JAMA. 2020;323(9):863-884. https:// jamanetwork.com/journals/jama/fullarticle/2762309?utm_ campaign=articlePDF&utm_medium=articlePDFlink&utm_ source=articlePDF&utm_content=jama.2020.0734. Accessed November 5, 2021.

Lang Aston, Chief Growth Officer for SpineZone