By: Chad E. Cook PT, PhD, FAPTA
Resource efficiency models
Musculoskeletal (MSK) outcomes have shown some concerning trends over the last decade. Conditions like low back pain, neck pain, and joint pain have become more prevalent, contributing to the overall burden of a MSK disorder [1]. According to a report analyzing medical claims data from 2010 to 2020, MSK healthcare costs have doubled, despite the number of individuals reporting MSK disorders remaining relatively constant. This increase in costs is driven by a rise in per-member costs and the growing number of health plan members [2] and has prompted a number of novel management models that emphasize cost-effectiveness rather than a current fee-for-service dominant strategy (which rewards higher utilization and does not penalize the provider when outcomes are not optimized). These novel “resource efficiency models” focus on the optimal use of resources—such as time, personnel, equipment, and finances—to achieve comparable or superior patient outcomes to a traditional approach.
What is Stepped Care?
Stepped care for MSK conditions is a tailored and structured approach to treatment that starts with the least intensive, most cost-effective interventions first (Figure 1). Care steps up to more intensive treatments as/if needed [3] (only when selected clinical criteria are not met or if the patient is at risk for worsening if they do not receive a dedicated treatment approach). The earliest stepped care options were developed for mental health disorders, diabetes, and other behavioral conditions and thus far there is emerging evidence to support stepped care treatments for individuals with different forms of MSK disorders [4-9].
It works off the premise that there logical are first-line and second-line approaches to MSK conditions, as well as a series of assumptions [10]. These assumptions include: 1) Equivalence of clinical outcomes across the different levels of care. These steps within the model are assumed to be equally effective in achieving clinical outcomes; 2) Efficiency in resource use: The model assumes that using the least intensive, yet effective, intervention first will optimize resource use and reduce costs; 3) Acceptability of minimal interventions: Patients and providers are assumed to accept and adhere to less intensive interventions before moving to more intensive ones (watchful waiting has merit); 4) Self-correcting nature of the model: The model assumes that if an intervention is not effective, the next step in the care pathway will be more intensive and appropriate and may potentially be a better “match” for the patient; and 5) Stepped care reduces overtreatment: Overtreatment in MSK conditions is the provision of medical interventions that are unnecessary or excessive given the patient’s condition.
Why Isn’t Everyone using Stepped Care?
Thus far, there seems to be both clinical efficiency of stepped care and cost-effectiveness as well. If so, especially in light of the rather stagnant results we’ve seen globally in management of MSK conditions, “why isn’t everyone using stepped care?”. The answer for the United States is threefold. First, care within the United States is fragmented, often leading to poor communication across different forms of providers. Second, the parties involved as first-point providers are often those who provide the most invasive and potentially highest costs of care (a proverbial fox guarding the chicken coup scenario). Last, there are no financial incentives in a fee for service system, the payment system that dominates the United States, for adopting stepped car. In fact, it is likely that fee for service providers would lose business to lower cost providers and would also lose market share.
Summary
Stepped care has significant potential for improving the management of MSK conditions in the future. By providing tailored interventions that match the patient’s needs, stepped care can enhance treatment outcomes, reduce healthcare costs, and improve patient satisfaction. This model allows for early intervention with less intensive treatments, reserving more resource-intensive options for those who do not respond to initial therapies. Additionally, stepped care promotes a more efficient use of healthcare resources and encourages a collaborative approach among healthcare providers. As research continues to support its effectiveness, and as payment models are adjusted, stepped care could become a cornerstone of MSK management, leading to better overall health outcomes for patients.
References
- GBD 2021 Other Musculoskeletal Disorders Collaborators. Global, regional, and national burden of other musculoskeletal disorders, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023 Oct 23;5(11):e670-e682.
- Hinge Health. State of MSK Report 2021. Downloaded on December 15, 2024 from: https://healthactioncouncil.org/getmedia/a738c3c5-7c23-4739-bb8d-069dd5f7406b/Hinge-Health-State-of-MSK-Report-2021.pdf
- Kongsted A, Kent P, Quicke JG, Skou ST, Hill JC. Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model? Pain Rep. 2020 Sep 23;5(5):e843
- Garcia AN, Cook CE, Rhon DI. Adherence to Stepped Care for Management of Musculoskeletal Knee Pain Leads to Lower Health Care Utilization, Costs, and Recurrence. Am J Med. 2021 Mar;134(3):351-360.e1.
- Rhon DI, Greenlee TA, Fritz JM. The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain. Pain Med. 2019 Mar 1;20(3):476-485.
- Kroenke K, Bair M, Damush T, Hoke S, Nicholas G, Kempf C, Huffman M, Wu J, Sutherland J. Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: design and practical implications of an intervention for comorbid pain and depression. Gen Hosp Psychiatry. 2007 Nov-Dec;29(6):506-17.
- Kroenke K, Krebs E, Wu J, Bair MJ, Damush T, Chumbler N, York T, Weitlauf S, McCalley S, Evans E, Barnd J, Yu Z. Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial study design and sample characteristics. Contemp Clin Trials. 2013 Mar;34(2):270-81.
- Mylenbusch H, Schepers M, Kleinjan E, Pol M, Tempelman H, Klopper-Kes H. Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes. Interv Pain Med. 2023 Nov 15;2(4):100292.
- Boyd L, Baker E, Reilly J. Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study. PLoS One. 2019 Apr 9;14(4):e0214715.
Figure 1. Example of a Stepped Care Model for Musculoskeletal Conditions.
