Hinge Health: Musculoskeletal Costs Doubled in Past Decade With No Benefit in Patient Outcomes

Representing one-sixth of all spending in the US health care market, the annual cost of musculoskeletal (MSK) care is greater than that of heart disease, cancer, and diabetes. In the past decade, MSK spend has nearly doubled from $10 billion to around $20 billion, although this increase in cost has not led to improved patient outcomes, according to Hinge Health’s State of MSK Report 2021.

The report indicates that 2 main trends have contributed to the significant increase in MSK cost: (1) per-member costs rising by 40% from 2010 to 2019 and (2) a 42% increase in the number of new health plan members during this time span despite the number of members filing MSK medical claims remaining roughly constant.

“Rising costs of MSK care mean employers and health plans should expect MSK to continue to be their top cost driver….Studies have shown that, despite a 65% increase in health care expenditures for patients with back and neck problems from 1997 to 2006, there has not been a corresponding improvement in patient clinical outcomes,” wrote the study authors.

So, what cost drivers are impacting MSK care?

In an email exchange with The American Journal of Managed Care^®, Hinge Health Chief Medical Officer Jeff Krauss, MD, said that reasons for skyrocketing MSK costs are evident when looking at how care has been delivered in the past decade.

“The utilization of outpatient services grew 50% in the last decade, a trend due in part to the over-prescribing of expensive technologies such as MRIs,” said Krauss.

As the report highlights, claims for MRIs and imaging have increased over the last 10 years along with cost (35%), driven primarily by increasing demand and not unit cost. Against best-practice guidelines, particularly early in treatment, MRIs can cause even worse pain for patients and lead to more invasive procedures like surgery and related high costs.

Another driver of high cost, inpatient spinal fusion unit costs increased by 89% from 2010 to 2019 due to more expensive techniques, implants, and biologics that have yet to be associated with long-term benefits.

“In outpatient settings, we’re seeing procedures including surgeries become more available on an outpatient basis, which could account for the increased utilization. Whereas the increase in emergency room (ER) visits could be due to the continued influx of people without access to health care insurance,”  said Krauss.

Speaking further on the rising use of outpatient facilities, Krauss says that there at least 5 reasons why MSK care has been trending toward outpatient surgery:

• outpatient surgery is generally less expensive. The overall concern over cost and increase in consumerism in health care (eg, high-deductible plans, price transparency) makes outpatient procedures more attractive
• medical innovations have allowed many otherwise inpatient procedures to be moved to an outpatient setting (eg, minimally invasive techniques, anesthesia protocols). For example, total knee replacements are often now performed as outpatient procedures in select patients
• the number of outpatient facilities (ie, ambulatory surgery centers) for patients to choose from continues to grow
• surgeons own or partly own the vast majority of surgery centers, which creates a financial incentive for them to operate there
• CMS moved many spine and orthopedic procedures off the Inpatient-Only list, meaning they can now be performed in an ambulatory setting while being eligible for reimbursement
  

With the shift to remote work amid the pandemic causing worsening pain or newfound pain in 70% of employees, the report provided recommendations for employer benefit leaders and health plans in advising members as they seek care.

Prioritizing conservative care like exercise therapy, authors say to be wary of ambulatory surgery centers, spine centers, and other outpatient centers where higher care volumes are possible, as well as to avoid dependency on short-term pain relief provided injections and other procedures that do not address the root of the issue.

“Benefits leaders and health plans should focus their efforts upstream—earlier in a patient’s MSK journey—with prevention programs and conservative care before MSK issues lead to expensive surgeries and ER visits downstream,” wrote the study authors.