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

2. The problem

3. 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

4. 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

5. ~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

6. The whole person

7. The environment

10. Society’s Influence

11. Where do consumers go to learn more?

12. What are we telling our patients?
Brian Justice, DC

13. “Blow the current system up” Lancet

14. 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

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

16. What does the evidence tell us?

17. “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

18. 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

19. 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.”

20. 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

21. How do we change?

22. 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

23. 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)

24. Success Stories

26. 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

28. 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

29. 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

30. 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

31. 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 Outcomes ? 5
Average Visits – Outcomes ? 31

32. 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
– 85th
Visit & Function
Outcomes Data
– 80th
– 85th 4
9.0 – 90th th
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

33. Technology

38. 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!

39. Questions?

40. Thank You