The Musculoskeletal Institute Lower Extremity Integrated Practice Unit (MSKI IPU)
Background: Joint pain secondary to osteoarthritis (OA) affects more than 300M adults worldwide, including 13% (32.5M) of adults in the U.S, with total expenditure exceeding $115B annually. OA can substantially impact a person’s quality of life, cause pain-related psychological distress, and lead to social isolation, rendering it a ‘whole person’ problem. Ageing populations, sedentary lifestyles, poor diet, obesity, loss of productivity, and utilization of high volumes of costly treatments, such as total joint replacement (TJR), intensify the burden of this condition.
Aim / Relevance: Our aim at the MSKI IPU is to provide high value, multi-disciplinary team-based, personalized care for patients experiencing joint pain through a condition-focused, risk-based
payment and practice model utilizing strategies centered around patient preferences.
The VBHC Initiative: The MSKI IPU opened in October 2017, provides ‘3600 whole person care’ for patients with musculoskeletal conditions including hip and knee OA. In this IPU we manage a diverse population-based in central Austin and surrounding regions, including underserved and vulnerable patients, with severe physical limitations, comorbidities, and psychosocial issues, under a condition-based bundled episode payment model. Appropriate care is provided by a highly coordinated multidisciplinary team, co-located within an outpatient facility, where providers are accountable for health-related outcomes and costs for episodes of care. Services include physical therapy (PT) (structured exercise programs), imaging, patient education, lifestyle modification (weight loss counseling; dietary advice), social support (smoking / alcohol cessation, case management, behavioral health (cognitive behavioral therapy; pain coping skills), pain management, and surgery. Team-members include an orthopedic surgeon and advanced practice provider (chiropractor or nurse practitioner), physical therapists, a dietician, behavioral health trained social workers, medical and administrative assistants, that use systematically and longitudinally tracked patient-reported outcomes and technologies such as A.I to drive shared decision-making.
Results Patients (n=2364) attending the MSKI IPU since inception demonstrated improved condition-specific health outcomes (measured using HOOS JR and KOOS JR) and general health
outcomes (PROMIS-Global-10). 90% with knee and hip OA achieved minimal clinically important difference and 79% with knee OA and 82% with hip OA achieved substantial clinical benefit (SCB)at 1 year. Costs of IPU-based care ranged widely based on the level of clinical complexity but average total costs remained lower than traditional management, both with and without TJR through
optimal use of PT and advanced providers, and reduced use of non-value adding treatments.
Collaborations & Partnerships The MSKI IPU initiative involves a unique partnership with the
local community (including taxpayers), payers, and ultimately patients. We are collaborating with a national network of learning health systems and organizations, and are partners in a
consortium with Duke Health and Duke Margolis Center for Health Policy, leading a national coalition for the advancement of the next generation of condition-based alternative payment models.
In Summary the MSKI IPU is unique in providing an innovative and comprehensive condition focused payment and practice model, built on the foundations of a tier 1 research university,
designed to provide VBHC for patients with common musculoskeletal problems at scale.