Employers spend more on musculoskeletal (MSK) health and associated comorbid conditions than on any other condition of chronic illness. Unnecessary or inappropriate care remains a significant part of those costs.
“One unique challenge in managing musculoskeletal disorders and chronic pain is finding the appropriate care at the appropriate time,” said Zack Papalia, Senior Population Health Consultant at Brown & Brown. “The complexity of the musculoskeletal treatment and care landscape creates a unique challenge both for patients and employers.”
Brown & Brown’s summer webinar series has focused on this challenge, which requires a comprehensive strategy that includes solutions for foundational well-being, prevention and early intervention, treatment access and cost, and treatment appropriateness and quality.
The most recent installment focused specifically on the levers employers can pull to impact appropriateness and quality — surgical COEs and expert medical opinions.
In addition to host Papalia, webinar participants included:
-Louise Short, National Clinical Leader at Brown & Brown
-Raymond Hwang, Vice President & Medical Director for Lantern (Formerly SurgeryPlus)
-Mark Griffin, Executive Vice President and Chief Human Resources Officer at BJ’s Wholesale Club
A few key takeaways:
-Quality and appropriateness vary widely. Many procedures are unnecessary and don’t resolve the underlying issue.
-When implementing a COE, employers should identify clinical and financial need, evaluate available solutions and providers and develop a proactive, targeted communication strategy.
-Driving initial and sustained adoption is critical when implementing a COE. Employees need to know what’s available, how it works and it has to be easy to use/integrate with existing solutions.
Appropriateness and Quality Gaps
When it comes to MSK, many procedures are unnecessary and/or do not resolve the underlying issue. And surgical quality and outcomes vary widely depending on the provider.
“As surgical costs continue to rise, the need for ensuring treatment appropriateness and steering members to the most clinically optimal treatment pathways with high-quality outcomes will only become more important,” Papalia said. “The two primary tactical avenues most commonly pursued relative to treatment quality and treatment appropriateness are Expert Medical Opinions, or second opinion services, and surgical Centers of Excellence.”
The primary and desired outcome for both of these tactics are ensuring members get the right care at the right time, and doing so in a way that produces high-quality outcomes while controlling costs.
Expert Medical Opinions: Sometimes called second opinion services, Expert Medical Opinions are becoming common in both carrier and third-party administrator arrangements, as well as integrated directly into many clinical third-party platforms. These platforms allow members to connect directly with world-class clinicians to discuss serious and complex conditions, regardless of their geographic location or local proximity to quality care. Many of these providers will work collaboratively with a patient’s local treating physician.
“Expert Medical Opinions are an increasingly common way to ensure treatment appropriateness and receive a high-quality clinical second opinion prior to pursuing a highly invasive or a high-cost procedure,” Papalia said. “EMOs have been shown to help organizations manage high-cost complex claims, provide the right diagnosis at the right time and aid in the development of a comprehensive treatment plan for members.”
Surgical Centers of Excellence: COEs are groups of providers with a proven track record of quality outcomes selected to perform specialized services on a specific procedure. Strategies employers use to implement COEs include carrier networks, independent COE networks and direct-to-provider contracting.
“The vast majority of large employers currently have at least one COE arrangement in place for specialty treatments, often through their existing carrier network,” Papalia said. “However, we’re seeing direct contracting with third-party COEs becoming more common in recent years.”
Evaluating Available Solutions and Providers
There’s no clear definition for a Center of Excellence, which is why it’s important to carefully vet solutions and providers. Key features consultants consider, according to Louise Short, National Practice Leader at Brown & Brown, are:
- Quality: “How does the network or provider measure quality? What are their historical outcomes?” Short asked. “Do they have data on return to work after surgical procedures, complications and readmissions? Any metrics like that are really important.”
- Second opinions: “Is there an embedded second opinion service to assure procedures are medically necessary and appropriate for the particular patient at that particular time?” Short added.
- Patient education and preparation: Ensure the provider educates the patient, includes them in decision-making and ensures they’re set up for success post-surgery.
- Member experience: “This has become more and more important to employers over the years,” Short says. “Employers are focused on, ‘Is this a concierge experience? Is there a navigator in the COE program? If so, how do they coordinate care? If the member has to travel, can the COE help set up that benefit and administer it?’”
- Cost: “Is it a bundled rate? Is there a warranty?” Short asked. “What are the performance guarantees?”
Raymond Hwang, Vice President & Medical Director for Lantern, stressed the importance of conducting quality checks at an individual versus facility level.
“The traditional COE approach has been facility-based,” Hwang said. “But buildings don’t perform surgery; people do. Even at the best-known hospitals with the best reputations, you’re going to have top performers, and by definition, those who aren’t top performers. At a more granular level, a top surgeon is not likely a top surgeon for every single surgery he or she performs.
“For example, some surgeons are really superb at total knee replacements, but the skills that make a surgeon great at total knee replacements don’t necessarily translate into, for example, total hip replacements,” Hwang added.
SurgeryPlus builds its network by individually vetting every surgeon on quality metrics, such as board certification, fellowship training, procedure volume, surgical avoidance rate and more.
“We vet them on the procedure level as well, so we can get a sense for exactly how they stack up on the procedures that a specific person may need,” Hwang said. “Then we vet the facilities they operate at along analogous quality dimensions. We really focus on the surgeon first, and the facility secondarily. As a side benefit, this approach increases access because members can now go wherever an excellent surgeon operates rather than having to travel to a specific big name facility or hospital.”
Mark Griffin, Executive Vice President and Chief Human Resources Officer at BJ’s Wholesale Club, is implementing SurgeryPlus for BJ Wholesales Club’s 35,000+ employee population for 2025. Member experience was a critical factor when evaluating providers.
“If employees have a poor experience, it reflects on how they feel the company values them,” Griffin said.
Implementation and Best Practices
When it comes to implementation, SurgeryPlus recommends employers waive member cost share to drive utilization.
“It makes surgery more accessible,” Hwang said. “We hear from members all the time that if it weren’t for SurgeryPlus [now Lantern], they wouldn’t have been able to afford surgery. You don’t ever really want cost to stand in the way of employees getting the healthcare they need.”
Short described waiving coinsurance as the carrot approach, or implementing mandates as a stick approach.
“People need to understand that the reason COEs may be mandatory is because the employer is really trying to make sure you’re getting a quality experience,” Short said. “It’s the way you communicate that mandatory piece that’s important.”
Communication strategy is fresh in Griffin’s mind.
“Most of BJ’s team members are frontline customer-facing employees who don’t have a company computer, so we have to reach them in other ways, including through their personal mobile devices,” Griffin said. “Healthcare is not easy to understand. You need to be able to translate a complex situation into something everybody can understand, and more importantly, explain how it can help them.”
Hwang also noted it’s important for solutions to integrate. For example, Lantern integrates with Hinge Health.
“When somebody goes through Hinge Health’s digital exercise therapy program, but ends up needing to have surgery, they can be routed to a SurgeryPlus [Lantern] surgeon,” Hwang said. “And conversely, when a SurgeryPlus [Lantern] surgeon recommends physical therapy instead of a surgery or as part of a perioperative care program, that member can then be connected directly with a program like Hinge Health.”
Integration, along with a seamless user experience, increases utilization.
“It needs to be easy,” Griffin said. “If it’s a great idea and well communicated, but hard for people to actually use, then the benefit will be underutilized. Driving initial and sustained adoption is the single most critical part in the process. Employees need to understand how the solution will make their lives easier and how to use it effectively. When this is achieved, employees really understand that the company values their health and wellbeing. That’s a tremendous win for the employer.”
