Talking With Dr. Jeff Krauss, Chief Medical Officer, Hinge Health

Hinge Health Chief Medical Officer Dr. Jeff Krauss is constantly looking for ways the program can improve to serve members' needs. His continued work treating patients outside of this role only reinforces what he knows about the power of digital health solutions.

Dr. Krauss sat down with Hinge Health Director of Content Marketing Jenny Sucov at the Movement 2023 conference in Chicago to talk more about this, new thinking about chronic pain, how to truly evaluate the ROI of an MSK care program, and what's on the horizon for Hinge Health.

Jenny Sucov (JS): In addition to your role at Hinge Health, you practice at a VA hospital. Tell me a little about your work with that population.

Dr. Jeff Krauss (DJK): I love being able to work there and at Hinge Health because it allows me to step outside of the digital health technology mindset and reground myself. I remember what care is like in the clinic and from a patient's perspective, and I hear what patients are really asking doctors.

I am always thinking about how we can design Hinge Health to better serve these patients. I'm often wishing VA patients had Hinge Health because so many that come to see us need to move. And while we prescribe physical therapy for them, they aren't really doing it. They're not moving.

They also need to work on other lifestyle changes and understand that being in pain doesn't mean that they are damaged or that it's unsafe to move.

I will often talk to them about that in clinic. But I see them for one visit. Then maybe I'll see them three or six months later—or maybe never.

A ton of what I tell them goes in one ear and out the other. But a digital health solution is with them every day. It can remind them to do their exercises and that it's safe to move. Those key messages are so important to recovery from chronic pain.

JS: How have you been working to evolve the Hinge Health product with personalization in mind?

DJK: There's news regarding Enso [a Hinge Health-exclusive, FDA-cleared wearable device that delivers electrical impulses to those with MSK pain].

We are working on a lot of different improvements to the waveforms that Enso delivers. There are hundreds of thousands of variations of the waveform we are using, so we are researching them in our hardware lab now. That will make Enso useful in various situations and for various types of pain.

We are working on a third generation of Enso that will have a lot of machine learning functionality built in so that the device can be optimized for a specific individual over time.

I could keep going on about exciting things, but the computer vision work we're doing is just mind-boggling and the potential there is so huge. Now, you can see it in the app. We can track 87 points on the body, which is a leap forward from sensors because you can look at the whole body.

And that's really just the start of what the computer vision team is envisioning. Once you can see the whole body with a camera, you can provide better guidance, track all kinds of motion, create all kinds of new and interactive gaming scenarios. There's a ton on the horizon.

JS: What's one big area you are focused on?

DJK: Better serving our high-risk population.

When you look at MSK costs, 5% of members in an employer's population drive 85% of costs. We really need to make sure that we identify that small group and give them all of the resources they need.

The identification piece is something we are doing a lot with right now.

We already have Hinge Connect which gives us access to EMR (electronic medical records) data. We ask a lot of questions in our AQ. We have machine learning that can help detect, from conversations with coaches, who might be at high risk. And we are getting claims data that can also help us identify people.

Once we've identified them, then we need to give them these solutions.

We can give somebody additional coaching so that they can really work on those lifestyle factors, for example. We can do additional PT support for high-risk members.

We can give them Enso or surgical decision support, in which a surgeon talks with a member about what they think the best plan of care is. We get all of their records and imaging, so we can really give them an informed opinion.

I'm really excited about the work that we are doing with our high-risk members.

JS: How can employers, health plans, and consultants evaluate ROI? What makes the way we evaluate it at Hinge Health different?

DJK: This is an important and complicated topic. There are a lot of crazy claims out there about ROI. If you hear 4x or 5x ROI, it's probably not a very credible solution.

ROI is really hard to achieve, and I have spent a lot of time looking at the data with my team. A 2x ROI is solid, assuming it's a real finding.

We do a number of things to make sure these findings are real.

First, you need to have a control group. You can't just look at a cost this year and a cost the next year and say, 'oh, it went down' or 'it didn't go up that much,' so we know that there was an effect.

We use something called propensity score matching. That means that for every Hinge Health member, we find somebody who is as identical to them as possible (same age, gender, co-morbidities, number of MSK claims, costs, etc.)

Then we look at the costs from a year before and a year after in both groups and find the differences. This is a much more rigorous methodology.

You also have to look at whether a study has been validated and by whom. Anyone can put out a study. Third-party validation is a leg up. If it has been validated by one of the more rigorous validations, that gives it more credibility because you've had real experts looking at it.

Hinge Health has been validated by Milliman and Willis Towers Watson, for example.

He continues, discussing how ROI is defined...

DJK: Medical claims are the important thing to realize, but ROI goes beyond that. Medical claims are the real hard-dollar savings, but there are really valuable VOI [value of investment] pieces.

We have a paper coming up about the reduction of opioid use in people who use Hinge Health vs. a control group. In reducing opioids you reduce the potential for addiction and improve productivity in your workplace.

There are a lot of benefits and things you can look at—member experience, outcomes, and satisfaction—that need to play a part in the overall value equation.

Download the largest-ever, independently reviewed medical claims analysis of a digital MSK solution.

JS: How does the thinking about chronic pain in the past differ from today?

DJK: There has been a fascinating shift in the last five years. The medical community is coming to realize what sounds like a small point, but has huge implications:

When you have chronic pain, the nervous system is very much involved and, oftentimes, more so than the musculoskeletal system.

For example, if somebody hits me, it affects my muscles, ligaments, tendons, cartilage, bone—whatever physical structure is involved. That's the musculoskeletal system.

But the nervous system—receptors, nerves, the spinal cord, the brain—is the other very big system at work, and it's often ignored.

With acute pain, the injury to the body relates to the amount of pain someone experiences. With chronic pain, that is not the case.

The nervous system can take on a life of its own, becoming overactivated and causing a person to feel pain even when the body has healed or at least walled off the danger.

The nervous system is really good at learning. If your nerves have wired together for years to make you feel pain, they become very good at making you continue to feel that pain.

The key to undoing that is decreasing the sensitivity of the nervous system or turning down the dial on that overactivity.

JS: How do we undo the overactivation of the nervous system that contributes to chronic pain?

DJK: Movement is where you have to start. Of course, it strengthens, stretches, and lubricates joints. It also seems to desensitize the nervous system, both at the receptor level and up through the brain.

We know that light-intensity movement desensitizes the nervous system. With time, they can start to do more and more intense movements.

I think light intensity might work so well because the brain sees you doing these exercises over and over. It sees that you're safe doing them, realizes there's less danger, and starts to make you feel less pain with that motion.

Mindset is the next step—rethinking pain. Once you realize you are safe and not damaged, a lot people suddenly feel better.

You need to reinforce messages to yourself that you are safe and that pain isn't something you're going to have forever really helps people.

There are lots of exercises Hinge Health has today and brain initiatives we want to offer going forward.

JS: What does "feet, forks, fingers, sleep, stress, and love" mean?

DJK: That's something Dr. David Katz at Yale's Preventive Medicine Institute came up with, and it's something I chat about often.

Feet represents to movement; fork is what you eat. Nutrition is really important for MSK pain coming down the nervous system because it can decrease inflammation and help reduce obesity, which puts extra weight on the joints.

Fingers relates to substances like tobacco, alcohol, and opioids. If someone has a substance abuse problem, that can really exacerbate their situation.

Sleep is obvious, and stress refers to the mindset piece we talked about earlier. Love is social connection. We try to build that in the Hinge Health app by having our coaches and groups.

Lifestyle, at the end of the day, is the best thing for reducing chronic pain. When you understand chronic pain that way, you understand why surgeries don't always work. If the fundamental problem is overactivity of the nervous system, and not damage to a bone, joint, cartilage, or whatever, going in and fixing that is not going to help.

These responses have been edited for clarity and brevity.

About Dr. Krauss

Dr. Jeff Krauss is board-certified in physiatry and lifestyle medicine. He is Hinge Health's chief medical officer and continues to practice part-time as a staff physician at a VA hospital. Additionally, Dr. Krauss is a clinical assistant professor in Stanford University's Department of Orthopedics.