Going beyond surgery avoidance to lower total cost of care

Health plans have spent years trying to curb soaring surgery utilization and costs through familiar tools: prior authorization, clinical review, network management. That approach makes sense—reduce unnecessary surgeries, reduce unnecessary spend.

That’s especially critical for preference-sensitive surgeries. These procedures—such as joint replacements, spine fusions, and angioplasties where multiple clinically appropriate treatment paths exist—account for as much as 30% of health plans’ medical spend. And nearly a third of them are medically inappropriate.

But reducing unnecessary surgeries isn’t the only path to cost savings. It only addresses part of the opportunity.

A bigger opportunity comes from teaching members moving forward with surgery to make informed care decisions, prepare effectively, and navigate their recovery with confidence.

A matched cohort study of more than 50,000 members found that member-focused surgical decision support programs can save health plans $5,154 in medical costs per participant, per year. The surprising part? Nearly two-thirds of those savings are driven by better surgical outcomes achieved through improved readiness and recovery support. By comparison, avoidance of inappropriate surgeries accounted for one-third of savings.

The best strategy to maximize cost savings for preference-sensitive surgeries results from pulling two levers: reducing surgeries that shouldn’t happen and improving the outcomes for those that do. Plans that only rely on utilization management risk leaving the majority of savings on the table.

A hidden cost driver: underprepared surgical patients
A critical starting place to improve surgical outcomes is to address health literacy—or the lack of it. Nearly 9 in 10 Americans struggle to find, understand, and use health information to make care decisions. Without this foundation, members struggle to truly grasp their individual risk factors, treatment options, necessary preparation, and realistic recovery expectations. A study of patients who underwent bunion surgery, for example, found that more than one-third didn’t know how long to wait before safely returning to low-impact activity.

The consequences of poor preparation extend across the episode of care and can show up later in costly ways: more emergency department visits, infection complications, medication misuse, and longer recoveries.

Member-focused shared decision support helps patients move forward with confidence in either direction: toward surgery—well-prepared—when it’s appropriate, or away from it when it isn’t. In fact, decision support programs have been shown to reduce patients’ procedure-related anxiety by 40%.

How shared decision support delivers
Structured shared decision support programs address knowledge gaps before surgical decisions are made. When members understand their treatment options, the tradeoffs of their treatment choice, what recovery actually requires, and how to effectively collaborate with their care team, they make more informed, less risky choices.

Plans that complement their current utilization management efforts with upstream shared decision support programs significantly reduce inappropriate surgeries, seeing 116 fewer per 1,000 program participants.

But just as important is the ability of these programs to tangibly improve surgical outcomes by teaching the members who proceed with surgery how to better prepare. As a result, for every 1,000 participants, plans see:

• 184 fewer emergency department visits
• 884 fewer inpatient days
• 82 fewer sepsis cases
• 23 fewer surgical complications

The next era of surgical cost management
Surgery avoidance and outcomes optimization aren’t competing strategies. They’re a result of the same underlying foundation: ensuring members have the education, support, and time they need to make informed decisions and successfully navigate their care.

Some members choose a non-surgical path. Others go forward with surgery but experience fewer complications and smoother recoveries because they were properly prepared. Both lower total cost of care. But increasingly, the largest savings aren’t from reducing unnecessary surgeries, but from ensuring the ones that do happen deliver better outcomes.

Register to receive the full findings of Paradigm’s Difference-in-Differences matched cohort study on the My Surgery digital shared decision support program.