Conservative Care for Musculoskeletal Conditions Patrick Tarnowski, PT, MBA Senior Director, Blue Cross Blue Shield of Minnesota Vice President, MN Physical Therapy Association

The problem

Musculoskeletal Conditions by the numbers Second largest contributor to disability worldwide Low back pain - single leading cause of disability globally (WHO) Increasing at 8-10% per year Does not discriminate by age

Musculoskeletal Conditions: data Musculoskeletal & Connective Tissue was the highest spend 33.8% of membership with any claims had spend associated with a MSK diagnosis As a primary diagnosis, this category accounted for 12.3% 51% went to Surgical spend and related professional fees 50% of members who had spend in this category had diagnostic radiology claims, accounting for 8.6% of related spend 32% of these members had Chiropractic spend, accounting for 2.6% of related spend

~50% of all MSK cases are non surgical They can be challenging Patient expectations and sentiment = bouncing Repeat evaluations Repeat/non evidence-based Imaging Poorly coordinated care Poor initial triage and routing Co morbidities Mental Health (anxiety, depression) Social determinants

The whole person

The environment

Society’s Influence

Where do consumers go to learn more?

What are we telling our patients? Brian Justice, DC

“Blow the current system up” Lancet

Where does care often begin? More than 10% of visits to primary care physicians relate to back or neck pain *12 lecture hours * 18 lab hours The American Journal of Orthopedics, March, 2015

What happens when care begins? What drives the cost? BCBSA March, 2019

What does the evidence tell us?

“In the year following their initial complaint to primary providers, the sample of people in the study who went to physical therapy directly spent an average of $1,871, compared to $6,664 for those who were first sent for an MRI.” Fritz 2015

US Surgeon General Jerome Adams “Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.” Rohn, 2019 “It is an indisputable fact that physical therapists are well-positioned to change the culture around pain management.” US Surgeon General Jerome Adams “The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.” Babatunde, 2017 Teletherapy can be equal to or more effective than hands on therapy

Why is this so hard? "The greatest challenge…is unwarranted variation—situations in which wide variation of care is not explained by the type or severity of the condition or by patient preferences…“ Manal, 2017 “…significant increase in the frequency of treatments that are considered discordant with current guidelines, including use of advanced imaging (ie, CT or MRI), referrals to other physicians (presumably for procedures or surgery), and use of narcotics…” JAMA, 2013 “The study reveals variability in timing, utilization and exercise content following TKR…” Oatis 2014 “…standardized rules … add value by reducing clinical chaos and improving outcomes. [They] assess risk and suggest matched-treatment interventions to maximize the success of your physical therapy care.“ Manal, 2017 “Staying current in clinical practice requires reading 34 articles/day.” 2009

Influencers Education Patient awareness of optimal care pathway and demand for unnecessary tests Incentives Reward for doing more Clinical Inconsistencies “My approach” Society Fix my pain

How do we change?

Multi Faceted Problem Change the approach Improve communication Biopsychosocial vs. pathoanatomical Improve communication Different languages Different expectations Understand that: Pain has emotional and cognitive elements Passive care can support active care Imaging can irrelevant findings Incentives are misaligned “It is far more important to know what person the disease has than what disease the person has.” Hippocrates

Implementing a conservative care model Use the evidence to drive practice Clinical practice guidelines Communication across all providers Recognize the reverse incentives Build collaborative referral relationships Eliminate barriers (real or perceived) to preferred pathway Unite around common outcome(s)

Success Stories

Spine Health Program 2 year pilot program evidence-influenced patient centered biopsychosocial model Strong emphasis on patient choice, education and motivation in self-care. Care is coordinated by either a primary care practitioner (PCP) or by a ‘primary spine practitioner’ (PSP), a pathway trained licensed health care provider (i.e. chiropractor, physician, physical therapist, nurse practitioner). 1) Zero Copay Yoga/movement training for a low socio- economic group Mindfulness training as a community program offering to introduce wider access to non-opioid, self-management techniques for spine pain

Spine Health Program Outcomes lower utilization of surgery (49%), imaging (45%), spine injections (59%) and of all spine services (30%). patient satisfaction scores above national averages

Driving Consistency and Reducing Waste in Physical Therapy Practice TPI is a MN based network of 16 Independent Practices, 34 locations and 150 Providers Use FOTO Outcomes and Database to guide care delivery Develop and manage VALUE BASED Contracts with Payers Hold clinics, providers ACCOUNTABLE to Outcomes Benchmarks

Complexity of loose knit independents Practice 3 Practice 4 1 Practice 2 Practice 8 Practice 7 Practice 6 Practice 5 Health Plan or ACO Contracting & Credentialing Process Claims from Practices Make Payments to Practices

Inconsistency of loose knit independents Practice 3 Ave Visits – 10.0 Outcomes - ?   4 Ave Visits – 18.5 Outcomes ? 1 Ave Visits – 12.5 Outcomes ? 2 Ave Visits – 14.1 Outcomes – ? Health Plan or ACO Invests to Control Cost UM for Cost Control Ave Visits – 12.0 Range – 8.5 to 18.5 Care Management for Quality No Consistent Quality Measures Practice 6 Average Visits - 9.8 Outcomes ? 5 Average Visits – 13.0 Outcomes ? 31

Predictability of MSO Therapy Partners Measures Outcomes Efficiency (Ave Visits or Cost) 8.5 visits Predictable Cost Effectiveness (Functional Improvement) 85th Percentile Predictable Functional Change Value (Improvement per Visit) 90th Percentile 1 9.5 – 85th Visit & Function Outcomes Data 2 9.5 – 80th 3 7.5 – 85th 4 9.0 – 90th 5 9.0 - 90th FOTO – 78% 6 8.6 – 90th Health Plan or ACO No Financial or Human Resources Devoted to Care or Utilization Management Saves $$$$ Visit & Functional Outcome Data 32

Technology

Key Takeaways The current MSK environment is challenging: Increasing costs Clinical approach that starts with and rewards “do something to you” vs. holistic conservative approach Societal influences Wide variation in care There is a preferred pathway (conservative care first): Decreases cost Improve outcomes Establishes a lifelong approach It’s possible!

Questions?

Thank You Patrick.Tarnowski@bluecrossmn.com