Top 5 Causes of Unnecessary MSK Surgeries – How Health Plans Can Respond

If you are a health plan leader that cares about not only cost savings, but member health improvement, then you need to know how to navigate these drivers of unnecessary costs.

The List:

1.???? Over-Reliance on Imaging Findings Many MSK conditions, like degenerative disc disease or meniscus tears, appear on MRIs and X-rays but may not actually be the source of pain. Providers sometimes recommend surgery based on these imaging results alone, rather than correlating them with clinical symptoms and functional limitations.

2.???? Ineffective Conservative Treatment Pathways Patients may not have fully explored conservative treatments like physical therapy, structured exercise programs, weight management, and pain management strategies before surgery is recommended. A lack of access, poor adherence, or insufficient time given for non-surgical options to work often leads to premature surgical interventions.

3.???? Financial Incentives and Fee-for-Service Payment Models In traditional fee-for-service healthcare systems, surgeons and hospitals are financially incentivized to perform procedures rather than pursue lower-cost, non-invasive treatments. This can lead to an overutilization of surgeries that may not provide significant benefits.

4.???? Patient Expectations and Misinformation Many patients believe surgery is the "quick fix" for their pain, often influenced by direct-to-consumer advertising, anecdotal success stories, or the perception that surgery is more effective than conservative care. Without proper education on risks, outcomes, and alternatives, patients may push for unnecessary procedures.

5.???? Lack of Shared Decision-Making In some cases, patients do not receive comprehensive, evidence-based counseling about the risks, benefits, and expected outcomes of surgery versus non-surgical options. Shared decision-making tools and patient-reported outcome measures (PROMs) are underutilized, leading to unnecessary procedures that may not align with the patient’s goals and lifestyle.

How Health Plan Leaders Can Navigate These Drivers

Upstream Clinical Engagement Programs: these programs deliver high-quality care that helps improve MSK symptoms in a lasting way, with a heavy emphasis on "patient activation." These programs can be in-person centers of excellence (see: Dell Medical School at the University of Texas at Austin MSK Institute) or digital programs such as Protera Health. Health plans can enroll at-risk MSK members to these programs through three routes:

• Claims-based identification: create list of ICD codes for high-cost MSK conditions and proactively outreach members with these codes in their claims history. The quicker you can engage them, the better chance you have at avoiding unnecessary utilization.
• Direct referrals: leverage existing care management programs or onboarding processes (ie Health Risk Assessments) to identify members with active MSK conditions for enrollment into the clinical engagement program (see above).
• Wraparounds for existing downstream utilization management (UM) programs: when members are denied imaging or treatments based on traditional UM parameters, it can be a very high-friction situation. Enrollment option into a clinical engagement program can decrease the friction.

Provider "Greenlighting": Given the high-friction nature of traditional ("downstream") UM, there has been increased emphasis on identifying alternative member- and provider-centered processes. One proposed mechanism has been provider "green lighting" for prior authorization. When health plans identify high-quality provider groups, they may exclude them from the traditional UM prior authorization processes with the caveat that this exclusion is conditional upon continued demonstration of high-quality and high-value care.

Greenlighting will provide incentives for providers to adhere to established (and transparent) quality standards while ensuring high-value care delivery.

PROMs: When there is concern that patients are not receiving adequate surgical counseling or decision-making, there is a higher likelihood of unnecessary MSK utilization. By rewarding provider groups that routinely collect and report PROMs (and ideally discuss them with the patient prior to surgery) - such as through "greenlighting" - health plans can encourage strong pre-operative behavior.

About Protera Health

Many health plans struggle to contain the rising costs of MSK care. Protera Health solves this problem through a virtual, physician-led, multidisciplinary approach. This results in not only lower costs of care, but also improved health outcomes and satisfaction as well.

If you are interested in learning how Protera can partner with your plan, you can learn more at our website.