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Musculoskeletal (MSK) disorders are one of the most prevalent chronic conditions affecting millions of Americans each year. According to the Cleveland Clinic-led research team, nearly 127.4 million adults in the U.S. experience MSK issues annually, making it the leading causes of disability in the country.¹ These conditions come at a steep cost: approximately $420 billion each year in direct healthcare expenses, including medical treatments, hospitalizations, and outpatient care - more than any other chronic condition.²
Given the sheer volume of MSK-related claims, the financial burden on patients, employers and insurers is substantial. Chronic MSK disorders are often not curable, meaning the cost of care is ongoing and can come at a steep price. The type of treatment and care a patient receives can vary depending on factors like the timing of their diagnosis, adherence to therapies, access to specialized care, and social or demographic determinants.
The Challenge for Actuaries and Underwriters
For underwriters and actuaries working in the insurance and reinsurance sectors, predicting and mitigating financial risk associated with MSK disorders presents a unique challenge. These conditions require careful consideration when determining appropriate coverage and setting competitive yet profitable premium rates.
Profitability in the insurance industry often hinges on one critical factor: accurately forecasting future healthcare claims costs and catastrophic claimant events. Even a single unanticipated catastrophic claim can be the difference between a profitable year and a financial loss. Given the complexity of chronic diseases like MSK, the potential for high-cost claimants requires insurers to maintain a delicate balance between competitiveness in pricing and sustainability in their business models.
How Artificial Intelligence (AI) is Transforming Risk Prediction
As healthcare expenses continue to rise, those in the insurance sector are increasingly looking toward innovative solutions such as AI and machine learning tools to help address the growing challenges in predicting and planning for future healthcare related costs. These technologies offer unprecedented opportunities to improve the accuracy of risk assessments and anticipate future claims. According to industry surveys, 76% of executives across the healthcare landscape are planning to adopt AI powered solutions in 2025 to help contain costs, improve patient outcomes, develop new therapies, and streamline efficiencies within the healthcare ecosystem.³
At Merit Medicine, we are leading the way in AI powered, risk prediction technology to enable actuaries and underwriters in the insurance industry to more accurately predict future claim costs and high-risk claimant events, providing them with the insights needed to assess risk confidently and write business that is both profitable and competitive - whether you have access to historical claims data across all your members, or if you need us to enable this visibility on your behalf.
Merit Medicine’s Approach: Predicting the Future of High Cost Claims
Our foundational model - Merit Predict, is trained on billions of data points, enabling us to confidently predict a patient’s unique healthcare journey over the next 12 to 18 months. By integrating a broad range of proprietary data sources—beyond traditional claims and census data alone—we offer a solution that sets new standards for accuracy in healthcare risk prediction.
With Merit Predict, carriers and underwriters gain access to comprehensive insights into their entire book of business. They can drill down into the unique, deidentified member-level data to uncover potential high-cost claimants and emerging healthcare risks. This predictive capability not only helps to reduce unnecessary costs but also enables insurers to price premiums more competitively, ultimately benefiting both the insurer and the employer.
The Long-Term Benefits of AI Powered, Risk Prediction for MSK Disorders
Being able to accurately predict future catastrophic events and MSK-related healthcare spend each year is a game-changer for health insurance underwriters and risk-bearing entities. By proactively identifying potential risks, customers can:
Price premiums more competitively: By accurately forecasting healthcare costs, underwriters can offer more precise pricing, ensuring they remain competitive while maintaining profitability.
Determine the appropriate levels of coverage needed: By identifying high-risk claimants early, underwriting teams can more accurately determine the most optimal levels of coverage needed and the appropriate stop loss spec deductibles for each client’s respective plan year.
Improve patient outcomes: With better risk management, insurers can work with healthcare providers and POC solutions to ensure that patients receive the right care at the right time, improving long-term health outcomes.
The Future of Risk Management in Healthcare
As we move into 2025 and beyond, the healthcare landscape will continue to evolve. The increasing prevalence of chronic conditions like MSK disorders, coupled with rising healthcare costs, underscores the need for advanced tools to navigate these challenges. AI and machine learning represent the future of healthcare risk prediction, and at Merit Medicine, we are leading the charge.
By leveraging the power of predictive analytics, insurers and underwriters can more confidently navigate the complexities of MSK disorders and other chronic conditions, ensuring that they can not only safeguard against financial risks but also improve the affordability and quality of healthcare for all.
Merit Medicine is at the forefront of AI-powered healthcare risk prediction. By embracing innovative technologies like Merit Predict, we empower insurers to more accurately assess risk, predict future claims, and write policies that are not only profitable but also offer competitive pricing for employers and their employees. Let us help you navigate the complexities of healthcare risk—today and in the future.
REFERENCE:
Cleveland Clinic. (2023, June 15). Musculoskeletal disease causes most disability, healthcare spending in U.S. but gets less than 2% of NIH research funds. ConsultQD. Retrieved from
Evernorth. (2023, February 23). The total cost of musculoskeletal conditions in health care. Retrieved from
https://www.evernorth.com/articles/health-care-total-cost-musculoskeletal-conditions
Healthcare Finance News. (2023, December 18). Trends for 2025: AI in healthcare progressing despite reimbursement hurdles. Retrieved from
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