Clinically Speaking: The Health Care Total Cost of Musculoskeletal Conditions

Musculoskeletal conditions affect more than 1 in 2 adults and cost our health care system an estimated $420 billion—more than any other chronic condition.

Stress, strains and long hours of sitting are taking a toll on musculoskeletal health, affecting more than 1 in 2 adults and costing the health care system an estimated $420 billion—more than diabetes, heart disease or any other chronic condition.

Nearly all health care spending on MSK conditions is concentrated in three subgroups:

  • Major trauma, such as fractures and crush injuries
  • Autoimmune conditions, such as rheumatoid arthritis
  • Wear and tear, which includes strains and sprains; more serious tears of muscles, tendons and ligaments; ruptured discs in the spine; and degenerative conditions of the joints

Wear and tear conditions

According to Evernorth data, wear and tear conditions account for 63.5% or nearly two thirds of all MSK-related utilization and spend.

In addition, comorbidities such as obesity, anxiety and depression are responsible for significantly higher spending on patients with wear and tear conditions, due to additional costs for inpatient and outpatient care, and for prescription drugs. For instance, average spend on patients with both a wear and tear condition and obesity is 80% higher than for those without obesity.

Similarly, 35% of patients with MSK wear and tear conditions have claims related to behavioral health, and the average spend for these patients is 66% higher than those without behavioral health conditions. Behavioral health comorbidities can create a vicious cycle, with an MSK condition negatively impacting mental health, which then disrupts the ability to manage an MSK condition.

Back conditions

Within the wear and tear subgroup, just five anatomic sites—back, knees, hips, neck and shoulders—are responsible for 80% of utilization and spend. Together, the back and neck, or spine, accounts for 42% of spending. And the back alone is the top cost driver at 29%. However, back conditions also present the greatest opportunity to affect change in utilization and spending.

For example, patients with high spending have an average of 10 unique clinical providers for their back condition compared to just two providers for patients with lower spending. Also, surgery, advanced imaging services and interventional pain injections are far more common among patients with more than $100,000 in spending on back conditions compared to those with lower spending. Yet, the International Association for the Study of Pain considers all these services to be of limited value for addressing low back pain. They add excessive costs, driving an inappropriate amount of spend on low-value measures.

Three ways plan sponsors can avoid wasteful spending

  1. Create clinical profiles: Organizing patients by clinical profile can help identify those with low, medium and high degrees of risk for surgery who may still benefit from underutilized, conservative measures like physical therapy. Studies show that adherence to physical therapy, especially early during treatment for low back pain, can help avoid surgery and reduce utilization and costs for patients with wear and tear conditions.
  2. Identify high-performing providers: High-performing providers deliver improved patient outcomes while controlling costs. Selecting these providers at the beginning of a patient’s journey is crucial as it can determine both the cost and course of treatment. Employing a scoring model, with weights assigned to each measure by clinical and research experts is one way to simplify the identification of high-performing providers who can guide patients to evidence-based, cost-effective treatment.
  3. Explore behavioral health treatment: MSK conditions often go hand in hand with anxiety and depression. Seeking behavioral health treatment can decrease the need for surgery, saving approximately $460 per patient per month.

After a dip during the COVID-19 pandemic, requests for advanced imaging for MSK diagnoses are on the rise, making actionable insights important to contain costs and improve care. To learn more, download the MSK Total Cost of Care report.

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Evernorth Guided Musculoskeletal Care
Through predictive models and a digital first personalized experience, Evernorth Guided Musculoskeletal Care connects patients at high risk of MSK conditions to the right care, at the right in a seamless approach that supports the whole person. In addition to concierge-style guidance to providers and treatment options, the comprehensive offering also includes mental health support, physical therapy, coaching and wellness to deliver better health outcomes.