How to achieve more inclusive MSK care

Staggering in both frequency and financial burden, musculoskeletal (MSK) conditions affect roughly half of U.S. adults — and more than 3 in 4 Americans over 65.¹ They're also among the greatest sources of medical spend, outpacing diabetes and cardiovascular disease. Low back and neck pain alone tallied $76.9 billion paid by private insurance and $45.2 billion by public insurance, according to the most recent data.

Beyond cost, these conditions can have a profound impact on quality of life. Back pain is the third most common cause of surgical procedures, and the most common diagnosis responsible for sick leave, long-term disability payments and early retirements.²

With the U.S. population aging and risk factors such as obesity rising,^3,4 MSK care is an area ripe for fresh attention. That urgency cannot be disentangled from the grim reality of certain health disparities. Like most corners of health care, these disparities tend to be complex and compounding.

Take hip and knee osteoarthritis, for example. Though research shows no significant difference in prevalence rates among different race and ethnic groups,⁵ there are profound disparities in health care utilization and health outcomes.⁶ Black and Hispanic Americans are far, far less likely than white Americans to have total knee replacement — as much as 30% less likely.⁷

When BIPOC patients do undergo orthopedic procedures, research shows they're more prone to complications within the first 90 days.⁷ They also face higher failure rates after total joint arthroplasty yet are less likely to have revision surgery than white patients. Those who do have revision surgery are more likely to experience infection and poor surgical efficacy.⁷

MSK patients in rural areas face similar disparities, including more limited access to care and fewer specialists. Rural Americans also have higher rates of comorbidities, such as obesity and smoking, that can increase their risk of MSK conditions and amplify their symptoms.⁸ As researchers have noted: "It is unrealistic to rely on the physician workforce alone to provide adequate musculoskeletal care in rural communities."⁸

The good news is that impact is possible. With a multifaceted, whole-person approach to addressing MSK care, health plans can take aim at these persistent health inequities and drive better, more equitable outcomes for all members. Here are some of the tools at payers' disposal.

Virtual solutions: Radically expanding access to care

When accessing MSK care depends on close proximity to a provider and readily available transportation, childcare and time away from work, that care is out of reach for many, many Americans. Virtual solutions — such as telehealth appointments with a licensed provider and digital resources — help erode common barriers, making MSK care more accessible for all.⁹

Virtual solutions can be a win for providers as well. For instance, rates of chronic pain are higher in rural areas than urban, yet research shows rural patients are less likely to have a provider recommend non-medication interventions, such as physical therapy.¹⁰

Similarly, Black patients suffering acute back pain are 63% more likely to receive opioid-only therapy from a provider than white patients, who tend to receive physical therapy referrals along with opioid therapies.¹¹ That disparity may stem, in part, from the provider’s own resource limitations and access issues. Just 22% of physicians provide care for 80% of Black Americans, and these providers report limited access to health care resources such as specialists.¹¹ Virtual solutions can help expand a provider's toolbox and better meet patient needs.

To meet the needs of diverse patient populations with varied preferences, digital fluencies and MSK conditions, health plans should span a wide array of virtual offerings. That might mean telehealth appointments with a provider, asynchronous video consults, or self-directed digital resources, such as lessons on musculoskeletal anatomy or guided meditations designed to ease pain-exacerbating stress. Kaia Health, an Optum partner program, provides physical exercises as well as education and relaxation modules complemented by access to Optum physical therapy health coaches.

Second opinion services: Increasing confidence for members and plans alike

Subspecialty second opinions within MSK medicine are often far more accurate than a patient's initial radiology-based diagnosis conducted by a non-specialist.¹² In fact, research has found that more than 4 in 5 of these second opinions were more accurate than the first diagnosis given.¹²

Yet getting a second opinion remains the exception, rather than the norm, as initiating and navigating the process often requires high health literacy, health care access and resources. Payers can reverse that stubborn reality by offering — and clearly promoting — a second opinion service to all members. Even better, integrating the service within the larger initiative of streamlining member navigation from first consult through full resolution ensures that all members know and understand how to make use of this valuable offering.

For instance, our partner 2nd.MD connects members to virtual second opinion consults and delivers results within 3 days, on average. By making second opinions both easily accessible and swift, payers can ensure that such offerings promote equitable utilization and outcomes.

Specialized nurses and care advocates: Improving health navigation for all

Primary care providers are often on the front lines when a patient has chronic back pain or other MSK condition. But even the best in-the-moment care may do little to ease barriers, like low health literacy or financial anxieties, that can threaten treatment adherence and make the right care at the right time more elusive.

For instance, Latino and Black older adults suffering from chronic low back pain are significantly more likely to use emergency department services than their white counterparts.¹³ They also tend to manage a higher number of prescription medications and experience more medication-related challenges, such as non-adherence or inappropriate medication use.¹³

One powerful antidote to the stubborn status quo? Offering members a concierge service that makes it remarkably easy for them to access high-quality, affordable care. When a member experiences a pain flare on the weekend, is the emergency room unavoidable? When a member is seeking an MSK specialist but is fearful of medical bills, how can they figure out their options? In moments like these, a web portal for browsing in-network providers and facilities simply won't cut it.

Instead of a one-size-fits-some offering, a concierge service provides targeted resources and guidance, tailored to the individual's needs, concerns and health literacy level. For instance, Optum® Specialist Management Solutions (SMS) connects members with local, in-network specialists that regularly use high-quality ambulatory surgery centers. Empowering an individual with specific guidance on the next best step to take can make it easier for them to follow through and take action — while delivering potentially significant cost savings, compared with accessing care at a facility plucked from the web portal. In fact, our SMS program has been shown to reduce targeted medical expenses for MSK, along with lower readmissions and reduced complications.

Members also have access to a specialized orthopedic nurse, who can engage in shared decision-making, coaching, and even pre- and post-surgery counseling. They might help members access resources for their behavioral health needs, connect them with pharmacy discount programs to bolster medication adherence, or talk through in detail what to expect from surgery recovery and how to prepare at home. The specifics are just that: specific to the individual.

Just as no single factor can fully explain the health disparities that dot the MSK care landscape, no stand-alone solution can fully address them. But integrated solutions that leverage a holistic, whole-person approach can help turn the tide — allowing health plans to provide the strongest care possible to every population it touches.

Learn more about Optum® MSK Solutions for health plans and employers.

1. United States Bone and Joint Health Initiative. Musculoskeletal diseases and the burden they cause in the United States. February 2023.
2. Solumsmoen S, Poulsen G, Kjellberg J, Melbye M, Munch TN. The impact of specialized treatment of low back pain on health care costs and productivity in a nationwide cohort. The Lancet Discovery Science. 2022;43:101247.
3. The Urban Institute. The US population is aging. Accessed February 12, 2023.
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13. Bazargan M, Loeza M, Ekwegh T, et al. Multi-dimensional impact of chronic low back pain among underserved African American and Latino older adults. Int J Environ Res Public Health. 2021;18(14):7246.