Addressing Musculoskeletal Conditions and Physical Therapy Needs with Virtual Solutions

The COVID-19 pandemic has accelerated adoption of virtual care. Telehealth digital solutions in the physical therapy (and musculoskeletal space more broadly) have garnered increased interest from employers and patients alike. This article summarizes emerging trends and considerations for employers looking to implement virtual MSK and physical therapy programs.

October 16, 2020

In 2020, large employers reported musculoskeletal (MSK) conditions as a top driver of their health care costs (Figure 1). In addition to the direct health care costs, these conditions have a material impact on employee productivity. More than 35 million adults with MSK conditions in the United States reported lost workdays in the previous 12 months, resulting in an average of nearly 10 days per employee and 364 million lost workdays total.1 MSK conditions are often accompanied by chronic pain as well as limited mobility and dexterity, with lower back pain being the single leading cause of disability globally.2 Patients suffering from these 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.

Large Employers’ Top Conditions Driving Cost, 2019-2020 
Figure 1: Large Employers’ Top Conditions Driving Cost, 2019-2020

Managing MSK pain centers on addressing its causes, which may include rounds of physical therapy, pain medications and/or other pain management techniques. Maintaining adherence to physical therapy regimens remains a challenge for many due to the burden of multiple in-person visits, which often are scheduled during workdays. For some patients, out-of-pocket costs are also a barrier to completing ongoing therapy visits.

As more employees work remotely, they may now spend hours at a time 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?

Musculoskeletal conditions consist of more than 150 diagnoses affecting muscles, bones, joints and associated tissues such as tendons and ligaments.2 They range from conditions with an acute onset, such as fractures, to lifelong conditions associated with ongoing pain and disability.

Examples of musculoskeletal conditions include, but are not limited to:

  • Sprains, strains, and tears
  • Back pain
  • Carpal tunnel syndrome
  • Arthritis
  • Connective tissue diseases and other pain disorders

Musculoskeletal conditions account for nearly 70 million physician office visits in the United States annually, and an estimated 130 million total health care encounters including outpatient, hospital, and emergency room visits.3 Workplace overexertion injuries are estimated to cost $15.1 billion a year and account for about 25% of total workers’ compensation costs.4 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. 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 .

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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 their care at high-performing providers and health systems.

Virtual MSK Solution Landscape

The COVID-19 pandemic of 2020 made it clear: The use of telehealth by PTs and PTAs is not only appropriate, but effective in delivering effective care and expanding patient access to that care.


American Physical Therapy Association (APTA)

The demand for physical therapists has long outpaced supply, particularly for those living in rural communities.5 Due both to limited physical mobility for those suffering from MSK conditions (which may make it more difficult for patients to travel to in-person visits) and social distancing guidelines, some employers have identified the need for additional points of access to MSK care. Business Group on Health’s 2021 Large Employers’ Health Care Strategy and Plan Design survey indicates the growing interest in expanding virtual care offerings for MSK care and physical therapy (Figure 2).

Large Employers’ Largest Expansions of Virtual Care Services, 2019-2023 
Figure 2: Large Employers’ Largest Expansions of Virtual Care Services, 2019-2023

Cost and inconvenience are the barriers cited most often to adhering to physical therapy treatment regimens. Recently, virtual solutions in the physical therapy and MSK space more broadly have garnered increased interest from employers. While telehealth can provide great value to both patients and providers, providing an end-to-end experience, including follow-up and encompassing patient-centered goals, is essential .


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 Physical Therapy

Traditional Physical Therapy Platforms

Digitally Enhanced Physical Therapy

Fully Digital Physical Therapy

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:

  • Is there a need not currently met by an existing physical therapy 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?
  • What is 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 their needs, employers should evaluate their workforce (e.g., determine risk factors for different job roles within the employee population) and conduct claims analyses with an eye for risk indicators, such as painkiller prescriptions, 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 it’s done 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 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 requisite 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 may allow 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 versus medical/clinical benefit) can have implications on overall engagement and utilization. While well-being platforms tend not to have high engagement, they can be utilized as a referral program 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. However, data sharing between health plans and vendors to utilize member data in a timely fashion remains a challenge.
  • How will the program’s performance be measured? Quantifying reductions in pain scores or other discrete clinical outcomes may not be possible for solutions without direct interactions with health care providers, although prescription fills 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.

Related Business Group Resources

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TABLE OF CONTENTS

  1. What Are Musculoskeletal Conditions?
  2. Virtual MSK Solution Landscape
  3. Key Factors to Consider When Choosing Virtual MSK/PT Solutions
  4. Related Business Group Resources