EviCore’s Dr. Robert Westergan on Managing Site of Care and Implants for Musculoskeletal (MSK) Conditions

Every year, more than half of adults – and nearly three-quarters of people over 65 – are impacted by musculoskeletal (MSK) conditions.[i] If they need surgery, the type of facility where the procedure is performed and the implant selected are the main cost drivers for both patients and payers. As part of our comprehensive MSK solution, EviCore offers programs to guide patients to the site of care and implantable device most appropriate for their condition.

MSK Surgeries: A Significant Cost for Health Plans and Patients

MSK surgeries are on the rise. One report found that MSK medical claims have doubled in the U.S. over the last decade, despite the population with MSK conditions remaining relatively constant.[ii]

EviCore’s expertise can help patients and plans avoid unnecessary MSK-related spending. “Starting from the beginning of this process, our MSK solution works to make sure the surgical procedure recommended for a patient is aligned with the latest evidence-based guidelines,” said Dr. Robert Westergan, a board-certified orthopedic surgeon and EviCore’s Associate Chief Medical Officer of Connected MSK Solutions. “This is an important first step because 25% to 40% of the care patients get for painful MSK conditions is of low value, meaning it’s unlikely to help them get better.[iii]

However, even once a patient is on the right treatment path, 75% of the remaining total cost of an MSK surgical episode is attributable to the site of care and the implantable devices.[iv] If not addressed, these factors could cost a health plan upwards of $120 per member per month.[v] For example, the costs associated with spine surgery range widely, from $5,800 to $76,300 for a spinal cord stimulator and $15,700 to $94,300 for a spinal fusion.[vi]  This variability can also mean much higher costs for patients, particularly those with high-deductible plans.

Optimizing the Site of Care Saves Money and Improves the Patient Experience

MSK surgeries and procedures can be performed as an inpatient or outpatient at a hospital, at an ambulatory surgery center (ASC), or in a physician’s office. “The costs can vary widely, but the outcomes are often as good or better at a lower-cost site of care,” added Dr. Westergan. “What’s more, patients typically prefer the experience at a non-hospital setting.”

For example, a 2019 study compared patient outcomes for hip and knee replacements performed inpatient at a hospital to those done at an ASC. It found no increased risk of 90-day complication rates or readmission rates in the ASC group, yet the cost of surgery was 40% less.[vii] At the same time, patients consistently rate their experiences at ASCs higher than those at hospital outpatient departments.[viii]

To help address these factors, EviCore’s MSK site of care program influences the selected location for surgical procedures, provides redirection support to help providers choose a more cost-effective location, and helps manage the inpatient length of stay, as needed. Patient safety is always our top priority, with financial factors only considered if we have established that a lower-cost facility would be equally (if not more) appropriate for their condition.  

Identifying Safety and Quality Gaps in Implant Utilization Improves Costs and Outcomes

There is wide variability in the utilization of implants. EviCore uses evidence-based clinical guidelines to identify safety and quality gaps in implant utilization. To provide an extra layer of protection, we also make sure the implant selected by the patient’s physician is not on the FDA’s recall list. Finally, we are able to perform a proprietary claims review to recoup potential overpayments.

This is important because the implant is one of the key cost drivers for an MSK surgical event, accounting for up to 87% of the cost in some instances. More than $150 billion is spent annually on medical devices in the U.S.[ix]  For implants, EviCore recovered 85% of identified savings within the first 90 days and $8,500 average savings per claim. [x]

EviCore’s MSK Clinical Team and Evidence-Based Guidelines Are Best in Class

With a team of over 100 surgeons, physicians, chiropractors, and therapists, the number of clinicians working on EviCore’s MSK solution is unmatched in the industry.

Additionally, the evidence-based guidelines we use for these programs include information from leading medical societies such as the American Academy of Orthopaedic Surgeons, as well as studies recently published in peer-reviewed medical journals. The guidelines are developed by physicians who are appropriately specialized and are reviewed by external subject matter experts. Guidelines are updated as often as twice a year and are available to anyone visiting EviCore’s Clinical Guidelines page.

“The results of our MSK utilization management programs are clear,” shared Dr. Westergan. “The patients we serve have low rates of surgical revisions, 30-day hospital readmissions, and post-surgery emergency department visits.” [xi]

Request a Complimentary Savings Analysis

We offer health plans an opportunity to evaluate their MSK-related challenges, including site of care and implant management. Learn more and take advantage of our complimentary saving analysis.

[i] Burden of Musculoskeletal Disease. Orthopaedic Research Society. 2018. 

[ii] 2022 State of MSK Report. Hinge Health. 2022.3 Cobos R, Latorre A, Aizpuru F, Guenaga JI, Sarasqueta C, Escobar A, García L, Herrera-Espiñeira C. Variability of indication criteria in knee and hip replacement: an observational study. BMC Musculoskelet Disord. 2010 Oct 26;11:249. doi: 10.1186/1471-2474-11-249. PMID: 20977745; PMCID: PMC2987974.

[iv] Analysis of EviCore/Evernorth data.

[v]Data based on MSK claims for a large commercial health plan membership over 3+ year period (2018-2021).

[vi] How much should your spinal surgery cost? New Choice Health. 

[vii] Ast, Michael P. No risk of complications for joint replacement in ambulatory surgery setting. Hospital for Special Surgery. 2019.

[viii] Leapfrog Group Series ‘Patient Experience During the Pandemic’ Indicates More Favorable Experiences for Outpatient Surgery at ASCs Than Hospital Outpatient Departments. The Leapfrog Group. April 2022. 

[ix] Okike K, O'Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, Cross WW 3rd, Garrigues GE, Harris MB, Lebrun CT. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff (Millwood). 2014 Jan;33(1):103-9. doi: 10.1377/hlthaff.2013.0453. PMID: 24395941; PMCID: PMC4389213. 

[x] Analysis of historical EviCore/Evernorth claims utilization data.

[xi]Data based on MSK claims for a large commercial health plan membership over 3+ year period (2018-2021).