Second Opinion plus COEs can help address avoidable MSK surgeries

Musculoskeletal (MSK) conditions are one of the biggest cost drivers in health care. Half of Americans live with one, and more than $600 billion is spent on MSK-related care every year.¹ 

Surgeries are an expensive piece of that puzzle. Orthopedic care — including high-cost spine and joint surgeries — makes up an estimated 10% of all U.S. healthcare spending.² And that number is only expected to increase.

Total knee replacements alone are projected to surge 85% between 2014 and 2030. Just a 1% reduction in knee and hip replacements could add up to $200 million in potential cost savings, not to mention sparing members from often difficult recoveries.³ 

For health plans, every surgery creates financial exposure — and the challenge isn’t just volume. While many patients undergo surgeries to ease pain or improve function, surgery doesn’t always solve the issue and can introduce the risk of complications. For spinal fusion, up to 18% of patients experience a complication such as a blood clot, stroke or infection.⁴ 

Surprisingly, as much as 75% of MSK surgeries may be avoidable with non-operative care.⁵ The gap between what care is typically offered and what is actually needed is where payers have an opportunity to intervene.  

To bend the MSK cost curve and improve outcomes, payers can reshape the care pathway by: 

• Expanding access to conservative care solutions that proactively connect members to evidence-based exercise therapy, behavioral support and lifestyle coaching 
• Making second opinions a standard clinical checkpoint to help ensure that surgery happens only when it's truly warranted 
• Steering surgical care to high-performing Centers of Excellence (COEs) to concentrate care in the hands of highly experienced providers 
• Leveraging a curated vendor network such as Optum Hub to connect to trusted partners providing physical therapy, nutrition and wellness coaching and second opinions 

Together, these approaches move MSK toward a value-based model where better outcomes and cost containment are complementary goals.    

For many MSK issues, clinical guidelines call for conservative care to come first. But that’s not what always happens. Instead, more than one-third of patients receive imaging, injections or even surgery before physical therapy.⁶

Each of these interventions increases cost and risk, usually without improving outcomes. For example, 90% to 95% of low back pain is nonspecific and can be managed through conservative treatments like physical therapy, exercise, lifestyle coaching and pain management.⁷ 

Early physical therapy has been shown to reduce the need for injections, medications, imaging and surgeries by as much as 60%.⁸ But physical therapy can require time, travel and sometimes referrals, things many members struggle to manage. At-home or digital-first MSK programs break down these barriers. 

Optum MSK Solutions, for example, connects members to:

• Personalized and physical therapy
• Remote monitoring
• Behavioral support

This helps members start conservative care sooner and stay engaged longer. 

The results are measurable. Participation in a digital MSK program is linked to a 58% lower risk of surgery at 12 months compared to in-person physical therapy.⁹ Meanwhile, MSK programs that provide guided physical therapy, behavioral support and education can lower per-member MSK spend by as much as $2,000 a year.¹⁰ 

By combining clinical guidance with behavioral support — such as mental health resources, physical activity coaching and pain management education — digital MSK programs help members build confidence in their recovery, reducing the chance that surgery becomes the default.   

Even with the best conservative care, some members will eventually require a surgical consult. Surgical recommendations, though, aren’t always consistent. Without a structured clinical review, variation can lead to unnecessary surgeries. 

That’s where Second Opinion comes in: not as a barrier to care but as a safeguard against premature or inappropriate intervention. Optum MSK Solutions provides virtual Second Opinion services that connect members with medical experts via live video consultation, allowing members to receive a comprehensive clinical review before surgery is performed. This helps support shared decision-making between patients and their surgeons. 

Consider the power of this approach: In a study of 1,088 patients referred for spine surgery, after a structured second opinion, 60.8% were redirected to nonsurgical care. Only 34.7% ultimately underwent surgery.¹¹

Second Opinion gives patients a second chance to ask questions and better understand their options. This is critical considering that 40% of providers say they don’t have the time or resources to fully walk patients through their condition and options.¹² And when members are engaged early, 74% choose less invasive, lower-cost options.   

When surgery is necessary, where it happens matters just as much as why. 

Outcomes and costs vary dramatically depending on factors such as surgeon volume and facility expertise. High-volume providers consistently deliver better outcomes — fewer complications, shorter lengths of stay and lower total cost of care — over lower-volume providers.¹³

The Optum COE network is composed of top-performing surgical centers with demonstrated expertise in specific procedures. The results are consistent:  

• 37% fewer complications for joint replacement surgeries¹⁴ 
• 23.3% fewer readmissions for spinal surgery¹⁵
• 28% savings on procedures performed at a surgical COE¹⁶

By concentrating complex surgeries in COEs, payers achieve not only better care for their members but also more financial predictability. This is because many COEs operate under bundled pricing models that can reduce unexpected costs.    

The most effective MSK strategies build multiple touchpoints along the care journey: 

• Conservative care offerings
• Structured second opinion programs
• High-quality COE network

Each layer serves a distinct purpose. High-quality conservative care prevents unnecessary escalation on the front end. Second opinions act as a clinical filter before surgery is performed. COEs ensure optimal outcomes when surgery is the right choice.

For payers, the potential impact is clear:

• Lower surgical volume
• More predictable costs
• Better long-term outcomes