Next-Generation Musculoskeletal Condition-based Care via Advanced IPUs

Advanced Comprehensive Musculoskeletal Care: The MSKI-IPUs at UTHA are unique specialty condition-based models of care driving health care transformation at the practice and policy level. Opening in October 2017, the IPUs provide ‘360° whole person care’ for a diverse array of patients, including those from minorities and vulnerable, underserved communities, experiencing a range of musculoskeletal conditions. The IPUs are designed to manage physical limitations, alongside mental and social health concerns under a specialty condition-based payment model. Appropriate care is provided by highly coordinated multi-disciplinary teams, colocated within an outpatient facility, where providers are accountable for health-related outcomes (patient reported outcome measures, PROMs) and total costs for episodes of care.

Services include physical therapy, structured exercise programs, self-management/patient education, imaging, lifestyle modification (weight loss counselling/ smoking/alcohol cessation), case management for social unmet needs, behavioral health (cognitive behavioral therapy, pain coping skills), pain management, and surgery. Team members include orthopaedic surgeons,
advanced practitioners, physical therapists, dietician, behavioral health-trained social workers, and medical assistants/patient navigators. Care is augmented by a virtual care platform using telehealth, PROMs platform driving decision support, an artificial intelligence-enabled patient decision aid providing personalized risk:benefit forecasts for surgery, and real time location systems (RTLS) to track team activity and develop scalable cost accounting models using time
driven activity-based costing (TDABC). Few such models exist in current musculoskeletal care.

Aim and Relevance: To provide exemplary high-value, specialty condition-based care for patients experiencing a range of painful musculoskeletal conditions via multi-disciplinary teams working within full risk-based, condition-focused payment model accountable for health-related outcomes and total costs of care using a range of evidence-based operative and non-operative strategies centered around patient preferences, value, and needs.

Patient Description and Involvement: A broad and diverse population from Central Texas and nationally including those with private insurance, Medicare/Medicaid and those from minorities, underserved, and vulnerable communities on a medical access program (MAP) insurance plan.

Methods: Analysis of prospectively and retrospectively collected data captured from
institutional databases, PROMs and RTLS platforms.

Size/Scope: The scope of our work spans comprehensive evaluation of health-related outcomes (including PROMs), health care utilization, and total costs of care (using technology-enabled TDABC) of patients with hip and knee OA managed at UTHA and expansion to a comparison site at University of Texas San Antonio (UTSA) providing procedure-oriented care under fee-forservice infrastructure.

Preliminary Results: A total of n=3173 patients from UTHA (2017-2022) demonstrated improved condition-specific health outcomes (HOOSJR/KOOSJR) and general health outcomes (PROMIS Global-10). ~91% with knee and hip OA achieved minimal clinically important difference (MCID) and 79% with knee OA and 82% with hip OA achieved substantial clinical benefit (SCB) at 1 year. Weighted average costs of IPU-based non-operative management ($464- $475) was lower than simulated traditional non-operative management ($795-$854) and lower
in IPU-based operative management ($15,738-$15,902) compared to simulated traditional operative management ($15,918-$16,162) with savings of up to 45.7%. Key drivers of reductions were use of associate providers, more personalized PT programs, and judicious use of intraarticular injections to offset incremental costs of behavioral-health trained social workers and nutritionists.