Avoiding Unnecessary Surgeries And Imaging (with Heidi Ojha)

This video provides an in-depth exploration of the pervasive issue of unnecessary surgeries and imaging, particularly within Musculoskeletal (MSK) care, and advocates for a shift towards conservative, patient-centered approaches. Hosted by Spencer of Self-Funded, the conversation features Heidi Ojha, founder and CEO of Aware Health, who shares her clinical and research insights into the flaws of the current healthcare system. The discussion highlights MSK as the leading driver of chronic healthcare spend, often overshadowed by high-cost, low-frequency conditions like cancer, and emphasizes the critical role of behavioral health comorbidities in influencing surgical decisions and patient outcomes.

Heidi Ojha, drawing from her background as a clinician and professor, reveals that an alarming 95% of elective orthopedic surgeries (such as shoulder/knee repairs, back fusions, and even some pelvic floor surgeries) are, on average, no more effective than doing nothing at all, especially when accounting for spontaneous recovery. This counterintuitive finding is attributed to misaligned incentives within the fee-for-service model, where providers are reimbursed more for procedures, and patients often seek quick fixes due to pain and time constraints, overlooking the potential harms and ineffectiveness of surgery. The discussion also touches upon the "white coat effect" and the over-specialization in healthcare, which can lead to misdiagnoses and treatments that address symptoms rather than root causes, as illustrated by a case of referred low back pain treated as a foot issue.

Aware Health's model is presented as a solution to these systemic problems. It focuses on empowering patients to avoid unnecessary surgeries by providing direct access to non-surgical specialists, leveraging diagnostic algorithms based on published research, and prioritizing conservative care upfront. The company aims to manage MSK spend for self-funded employers by reducing the frequency of costly interventions, offering a money-back guarantee on their services, and achieving significant ROI by preventing surgeries that average tens of thousands of dollars each. The conversation underscores the importance of data accessibility for understanding group-specific MSK spend and highlights how factors like geographic location (ZIP code) and the number of surgeons in an area can disproportionately influence surgical rates, rather than actual medical necessity.

Key Takeaways:

• MSK is the Top Chronic Spend Driver: Musculoskeletal conditions are the leading cause of chronic healthcare spending, surpassing cardiovascular disease, diabetes, and cancer when combined with behavioral health. This category is often overlooked by employers and advisors due to its "death by a thousand cuts" nature, comprising many medium-sized claims rather than a few catastrophic ones.
• Ineffectiveness of Elective Surgeries: Research indicates that, on average, 95% of elective orthopedic surgeries (e.g., shoulder/knee repairs, back fusions) are no more effective than conservative care or doing nothing at all, especially when considering spontaneous recovery.
• Misaligned Incentives Drive Unnecessary Care: The fee-for-service model incentivizes more procedures, leading to over-prescription of surgeries and imaging. This system pushes productivity over quality, reducing the time providers spend understanding patient needs and root causes.
• Behavioral Health's Crucial Role: Behavioral health comorbidities (anxiety, depression) are the biggest drivers of surgical decisions for conditions like back pain, even more so than the severity of tissue damage seen on imaging. Anxiety-provoking MRI reports can lead to self-labeling and fear-avoidance behaviors that exacerbate pain and prolong recovery.
• Imaging is Often Unnecessary and Harmful: While intuitively appealing, imaging (X-rays, MRIs) is frequently over-ordered. It's often not helpful for diagnosis in most MSK cases and can be harmful by increasing patient anxiety and leading to unnecessary interventions, rather than providing clarity.
• Conservative Care First: Patients in pain should first consult non-surgical specialists (like physical therapists) who are trained in comprehensive history-taking and objective exams to identify root causes, rather than immediately seeking surgical opinions which primarily focus on surgical candidacy.
• Aware Health's Model for Cost Savings: Aware Health offers direct access to non-surgical specialists, leveraging diagnostic algorithms to determine the necessity of imaging (only 3-5% of cases require it) and surgery. This approach significantly reduces MSK spend for self-funded employers, with observed ROIs ranging from 1x to 5.3x.
• The "Cost of Doing Nothing" is Substantial: Delaying the implementation of solutions to manage MSK spend results in continuous financial bleeding for employers, as unnecessary surgeries and prolonged treatments accumulate significant costs monthly.
• Patient Empowerment and Education are Key: A patient-centered approach involves collaborative care, where patients are heard and co-create their treatment plans. Reassurance, education about pain science, and activity guidelines (e.g., "million ways to move" instead of complete rest) are vital for reducing fear, promoting recovery, and avoiding self-fulfilling prophecies of chronic pain.
• Data-Driven Optimization: Continuously analyzing claims data is crucial for identifying high-risk cases, iterating on diagnostic algorithms, and proving the effectiveness of interventions. This allows for proactive management of expensive claims, rather than reacting after they've occurred.
• Targeting Self-Funded Mid-Market Employers: Aware Health primarily serves self-funded groups with over 500 eligible members, as claims data access is essential for their diagnostic system and demonstrating ROI. The implementation can occur off-anniversary, as it's an add-on benefit.

Key Concepts:

• MSK Chronic Spend: The significant financial burden associated with musculoskeletal conditions, often underestimated due to the nature of claims.
• Fee-for-Service Model: A payment model where healthcare providers are paid for each service they perform, which can create incentives for over-treatment.
• Conservative Care: Non-surgical, minimally invasive treatments and management strategies for health conditions, often involving physical therapy, education, and lifestyle modifications.
• Behavioral Health Comorbidities: The co-occurrence of mental health conditions (e.g., anxiety, depression) with physical health problems, which can significantly impact pain perception, treatment seeking, and outcomes.
• Diagnostic Algorithms: Rule-based systems or computational models used to aid in medical diagnosis, often leveraging research and clinical decision rules to determine the likelihood of conditions or the necessity of further tests.
• Paro Optimality Principle: An economic concept where resources are allocated such that no individual can be made better off without making at least one individual worse off, implying an optimal state of resource distribution. The video suggests that solutions like Aware Health can achieve a state where all stakeholders (employer, patient, provider) benefit.

Examples/Case Studies:

• Ankle Sprain Scenario: A patient with a rolled ankle, fearing a fracture, would typically go to the ER for imaging. Aware Health's algorithms use decision rules (e.g., ability to walk four steps, specific tenderness points) to determine a 0% chance of fracture within a 25-minute call, avoiding unnecessary ER visits and imaging.
• Referred Low Back Pain: A patient with leg pain and foot numbness saw a foot surgeon and was scheduled for foot surgery. A physical therapist identified the pain as referred from the low back, highlighting a misdiagnosis due to over-specialization and the need for a holistic view.
• Physical Therapist Fired for Good Outcomes: A physical therapy student was fired because his outcomes were "too good," resolving low back pain in one or two visits. This illustrates how the fee-for-service model can disincentivize efficient, effective care in favor of prolonged treatment.
• Acute Low Back Pain Mismanagement: A patient with acute low back pain (best prognosis) was given an MRI, prescribed opioids, and told her condition was unlikely to resolve without treatment, leading to a longer bout of pain than if she had received simple reassurance and activity guidance.