10 key insights for your musculoskeletal care strategy

1. What are the most common MSK issues workers face today, and how does it vary for diverse populations?

Musculoskeletal issues do not discriminate. I think we commonly think that, oh, it's only for those that are in physically demanding jobs. Well, the reality is that we see, at Marathon Health, regardless of industry, MSK or musculoskeletal conditions are usually a top three driver of cost for all of our patient populations that we see, regardless of work style or physicality of work.

And I will say the top one we usually see is low back pain. That's usually number one regardless of job demand. Usually followed by neck pain, shoulder pain, knee and hip pain then comes in around third or fourth, and then a range of overuse injuries. So think of your tendonitises, your carpal tunnels, things like that. And they can develop gradually over time. They could be acute in nature. They can be chronic in nature. So we're kind of seeing that wide spectrum of chronicity too.

And I think when we think about what the differences are between that more sedentary worker versus that worker who's in a more physically demanding job, what we see with our sedentary work population—for those that are not out in the field, banging a hammer, lifting heavy things—is they usually struggle with neck, upper back, and low back pain, and it's usually due to static posturing. So sitting for long durations of time, a poor workstation setup—ergonomically, they're not in the best position, whether that's their computer screen, things like that.

And then obviously our folks in physically demanding roles—our laborers, our police, our fire, our city workers, our manufacturing clients—they're exposed to repetitive forces at high load, high frequency, in awkward positions, which usually result in cumulative strain, as well as just acute injuries on the job. So I think the most important thing is that we have to tailor our treatments and even our prevention strategies for each group, on that individual need basis, not in just that overarching manner.

2. Musculoskeletal care is one of the largest drivers of employer healthcare spend. Why is that?

MSK is really prevalent. One out of two adults over the age of 18 will have an MSK condition at some point in their life. So it's really a highly prevalent condition.

And the problem is we have a ton of opportunity as a consumer of healthcare to seek care. Pain will drive us to seek care. It is one thing that will drive us to seek care. Those folks that want to know about their blood pressure or if they're diabetic—that generally doesn't drive people to seek care. Those are things that are generally asymptomatic until it's too out of control. Those are the silent killers, right? Blood pressure, diabetes—because we don't see a lot of symptoms until it's kind of too late almost.

As a consumer of healthcare, I have a ton of options to go seek care in the musculoskeletal realm. So I can go directly to my primary care. I can go directly to orthopedic surgery. I can go to the ED. I can go to the urgent care. I can go see a physical therapist, a chiropractor, a massage therapist, an acupuncturist. So the list goes on and on. And we are, as humans, going to chase an answer to our pain. That's just human intuition. We want to get out of pain. We want to return back to the things we enjoy doing in a pain-free fashion. So until we find that right person or that right avenue of care that's going to give us that relief, we're going to continue to seek care.

So what does that mean? That means we may encounter a bunch of low-value care. We may get sent for imaging that we don't really need. Upon that imaging, they may find in a static image something that seems abnormal or pathological, and then that gets in the hands of an orthopedic surgeon. The surgeon says, "Based on your image, I can fix that." Well, in reality, we know that imaging doesn't necessarily tell the whole story. So we get pigeonholed into a surgery we may not need, which maybe puts us in more of a disability, which reduces our presenteeism, causes more absenteeism at work.

As an employee, we're not able to provide for our family financially. As an employer, we're having to backfill a role and pay extra for a role. So you can see how all those costs start to compound on one another.

3. Virtual-only MSK programs are on the rise. What are the pros and cons to this approach?

When we think about virtual-only programs, from an employer standpoint and even from an employee standpoint, it's a convenience factor. They can do it when they want to do it. It's a cost factor. Inherently, we're all told that it's cheaper than getting in-person care and things of that nature. It's extremely scalable. We can give it across a really remote population, across a diverse workforce. And from an employer standpoint, it checks the box. I have a strategy in place to address my MSK problem. So that certainly made those programs attractive.

And I think when we start to see why they may have fallen short, it boils down to utilization, right? Are employers seeing the utilization? Are employees uptaking that and consuming that method of care on a very large scale? What do the outcomes look like? How are we tracking outcomes? What are meaningful metrics of those programs? And then, are we actually getting true MSK care by a licensed professional across the entire journey of a digital-only program?

And the reality is we're probably not. As we start to look at digital-only programs, you will probably be triaged by an MSK professional, a licensed professional. You'll be bucketed into a category or a pathway or an algorithmic care model. And then you're probably going to be supported, for the most part, by a health coach, with that MSK professional monitoring your dashboard in the background and looking for change in pain and things like that that may elicit another meeting with the MSK professional.

But in reality, it's managed a lot by a health coach. Again, nothing wrong with that. There's really a lot of importance to behavioral change and modification. We see that within our own programs here. That's a huge component of what we do as MSK professionals—working through those stages of change with the patient, to understand where they're at in their journey.

And I think probably that's where that kind of disenfranchising comes with the patient—it's great, I can do it when I want, I can come home from work and do it, but in reality I don't have that interpersonal connection with someone to guide me along my way or answer questions when I have really specific questions about my MSK problem.

4. What is a hybrid approach—combining in-person and virtual care—for MSK look like?

I think the hybrid MSK approach really means meeting the patient where they're at on their journey, and a hybrid approach really does that. It allows the patient to almost self-select how they want to receive care—whether that's in person, whether that's virtually via video-based, whether that's even some asynchronous management via SMS messaging or updating their home exercise program on the fly in between sessions. But it allows that patient to really get the care they want at the time they want it in the form that they want it.

5. What are the key benefits of integrated MSK and advanced primary care?

I think what we found—and what really separates this model apart from an MSK model—is that we do have that unique ability to access primary care for our patients that we're serving in an MSK population. And it's—I always say it's kind of a bidirectional workflow. Our MSK providers, whether that's our chiropractors or physical therapists, our massage therapists, our industrial athletic trainers, can actually act as a conduit or a secondary door to our primary care team. So we may be their first point of engagement.

And our providers are trained to take that primary care mindset and apply it to MSK—to understand the overall health of the patients that we're servicing and how we can leverage our advanced primary care to improve their overall health.

We also know that chronic disease and metabolic disease specifically—so think hypertension, diabetes, obesity, hyperlipidemia—all of those things impact musculoskeletal health and inflammation. So as an MSK provider, if we are solely looking at someone who's coming in with back pain and not understanding their metabolic health as well—Are you diabetic? Are you hypertensive? Do you have high cholesterol? What's your BMI?—and we're not addressing those things, that person is going to be stuck in a chronic cycle that we can't get out of.

And what we found is that by integrating those two and having our primary care team really involved in chronic disease management, and our MSK team understanding who needs to be referred in, and our primary care understanding who then needs to be referred in to PT or chiro if they're having back pain that's limiting them from being active—which would be really helpful for their metabolic disease—all of those things are really intertwined and intersect.

It's almost like a Venn diagram. Like you start removing pieces and you're never going to address the whole health of the patient.

6. How does a value-based MSK care model differ from the traditional visit-based approach to physical therapy?

In our model of care, we really focus on outcomes, efficiencies, and really trying to impact as much of the population as we can service. And that's really important. It's that population health mindset. And if we focus on outcomes and we focus on efficiency, we can really ingest more of the population health—or more of the population.

Whereas that traditional visit-based, community care-based is a fee-for-service model, and they're incentivized to see the patient for more visits for a longer period of time, and not as much incentivized to really get the patient better in an expedited fashion. And the reality is that's what patients want. They want to get better in a faster way. They want to self-manage their condition. They want to be given the tools to get better.

And that's really the differentiator—we are focused solely on driving outcomes for the patient and driving meaningful outcomes for the patient. We want to understand what they want to achieve with their care here, and then really working towards driving that individualized approach and giving them the means to get to their goals as well.

7. How does value-based, conservative MSK care help patients achieve results faster?

I think it's a couple things. We really promote direct access to PT care or chiro care or our MSK platform. We really want people to get in when their symptoms are in that acute or subacute region versus that chronic region. And why is that? We know that if we can get them in early and address their symptoms early, the likelihood of them moving on to more chronic problems becomes significantly reduced.

I believe it has to do with our integration with advanced primary care. If people's metabolic health is being better managed, their MSK episodes should be shorter in duration. That consistent inflammatory response is diminished and reduced.

We really focus on patient education and evidence-based care. We've kind of pulled away from that modality-based, significant passive modality-based care, to focus on educating the patient and empowering them to self-manage their condition via activity, via education, via motivational interviewing, reducing fear avoidance, all those things.

And then also, our incentives are really aligned around value and not volume. So our MSK providers are not incentivized to see people for a long time to capture more fee-for-service billing. They're incentivized to drive outcomes and see more of the population.

8. What are the advantages of an onsite or nearsite model for MSK care?

I think number one, and probably the most important thing with our providers being onsite, is we have the unique ability to gain their trust. And with that trust building—and I think that's kind of that differentiator between digital-only MSK solutions versus that hybrid approach or being onsite or nearsite—is the ability to develop trust.

And what does that create? That creates the employee population understanding that, "Hey, I want to go seek care with my Marathon Health MSK provider before I go see anyone else in the community."

Why is that important? Because we know that if they see us first, the likelihood of them having those downstream costly events—like imaging and surgical intervention, injections, things of that nature—becomes a lot less, and that's savings to the employee and to the employer.

But it starts with that trust. I also think it really supports early engagement, so patients want to engage with us sooner rather than later. And it also allows us to work on prevention too, which is really important. In the community, we don't have that unique ability to work on prevention, but because we're dedicated or at a nearsite or onsite location, we have the unique ability to work with the employer to understand where their physical pain points are.

9. How should employers measure ROI of this musculoskeletal benefits strategy?

I think one really big thing we focus on is efficiency of care. We're way more efficient than the community, which will significantly help from a redirected care savings model.

But also, we're really starting to dive into tracking—just like we talked about—surgical avoidance for those that are engaged, ortho avoidance, imaging avoidance, injection avoidance. We know that if we can engage people in an efficient manner, engage them early, keep them engaged, and understand that we're their trusted source should they have a similar problem in the near future—they should reengage with us—we know then that will prevent those downstream items from happening.

And that's where the large savings come from: reducing those downstream events.

10. For plan sponsors launching or expanding an MSK program, what should they consider?

I think number one is how easy is it for their employees to access? I think the biggest barrier to care for patients in the MSK space is ease of access. Do I have to wait a long time to get my appointment scheduled? If I do, the likelihood of me actually showing up to that appointment is going to be reduced, and I may seek care at a lower-value care option like an urgent care, an emergency room, an orthopedic surgeon—prior to seeing an MSK specialist.

So ease of access, decreasing the financial burden for the patient, is a huge thing. Most of our centers are low to no cost for the employee, so that really will motivate them to come use us—versus if I have to pay a $30 copay and I'm going to be seen two to three times a week in the community, that's $60 to $90 out of my pocket that I could use to pay for groceries, pay my gas, things like that.

I think reducing those entry-level burdens for the patient is huge, and that's a really huge factor for a lot of our employers who choose to add the service.

A couple other things to about when you're selecting an MSK solution for employers:

• What do your outcomes look like?

• How are you tracking outcomes?

• How are you reporting back to the employer on the outcomes that you're achieving with this solution?

• What does that downstream ROI look like?

• What does your cost savings look like from surgical avoidance, injection avoidance, imaging avoidance, ortho referral avoidance?

Things of that nature, where things really start to balloon in cost from an MSK or musculoskeletal perspective.

I think the other huge value is how do you integrate with primary care? Does your solution integrate with primary care? Because we know that intersection and that intertwining of those two things are so valuable for managing chronic disease and how that translates into the MSK population. Do they have a hybrid approach? Can they meet the patient where they're at on their journey of care?