Spine fusions are surging. Cataract surgeries will likely double in the next two decades. And hip replacements are on track to increase 176% by 2040. Health plan leaders see these numbers. What they don’t see is the thread that connects them.
These aren’t just high-volume procedures trending in the same direction. They are examples of preference-sensitive surgeries—procedures with two or more non-surgical treatment alternatives where the best option is closely tied to a patient’s risk factors and goals. These surgeries cut across virtually every specialty and account for 30% of health plan medical spend. Yet they’re not a cleanly categorized line item health plans can watch.
Instead, most payers account for surgeries in specialty-specific silos—from musculoskeletal to cardiac to ear, nose, and throat and more. They track spend by specialty, but don’t have a clear picture of overall surgical utilization and costs.
A costly category
When preference-sensitive procedures are examined as a single category, their financial impact comes into sharper focus. Preference-sensitive surgeries are highly prevalent, overused and growing by an estimated 4% to 6% per year. What’s even more concerning is that up to 30% of these procedures are medically inappropriate.
The examples are striking. More than one-third of knee replacements are considered unnecessary and 22% of coronary stents meet the criteria for overuse. Studies suggest that more than half of lumbar spine surgeries are deemed unnecessary. That adds up to real costs: for commercial plans, inappropriate preference-sensitive surgeries cost roughly $39 million a year per 100,000 members. For Medicare Advantage, that figure climbs to $66 million.
But even necessary surgeries carry risk. Up to 15% of surgical patients experience a postoperative complication. When factoring in ER visits, readmissions, extended recovery and follow-up care, costs quickly climb.
The health literacy gap
Behind every preference-sensitive surgery is a patient who made a consequential decision—often with limited information.
Nearly 9 in 10 Americans lack proficient health literacy. As a result, many patients make medical decisions without fully understanding the risks, realistic benefits or recovery timelines. The gap not only negatively affects the patient experience and erodes trust in the healthcare system when treatment outcomes don’t meet expectations, but uninformed decision-making drives excess utilization and spend.
Along with complications, patient surgery regret is also very real. The good news? Research shows that regret—which influences treatment adherence and recovery success—isn’t inevitable. When patients are better educated about their treatment, participate in shared decision-making and discuss factors like pain tolerance, physical activity goals and risk tolerance ahead of time, regret drops.
Surgery is often the right answer. But patients, in partnership with their providers, should choose a treatment because it’s the best option—not because it’s the only one.
The upstream opportunity for health plans
Health plans already deploy several tools to manage surgical utilization, such as prior authorization, clinical review and network management. But these are all downstream interventions that reach members after they’ve already committed to having a procedure. In other words, they come into play too late to influence the treatment decision.
However, there’s still room to meaningfully impact surgical utilization and costs, upstream. Plans can help close health literacy gaps by reaching members earlier in the decision-making process.
Structured shared decision support programs do exactly that. They give members clear information about their condition, their treatment alternatives, realistic recovery timelines and personal risk factors, and teach them how to collaborate with their provider to make the most appropriate treatment decision. When patients have access to these tools, member demand for inappropriate surgeries decreases, with 35% choosing an alternative to surgery. And when they do choose surgery, they are better prepared, experiencing fewer post-surgical complications. The benefits don’t end there—the skills learned through shared decision support programs empower patients to better navigate all types of healthcare decisions for the rest of their lives.
A wholistic surgery strategy
The best strategy to keep preference-sensitive surgery spend in check is one that combines both upstream and downstream efforts. This tag-team approach benefits health plans and their members in multiple ways: less overuse, lower costs, better treatment outcomes and members who feel genuinely supported.
That’s critical since the surgery surge isn't slowing down. By breaking preference-sensitive surgeries free from their silos—and investing in upstream levers—health plans and patients alike will be better prepared to make smarter surgery decisions.
Paradigm’s My Surgery solution is a digital, shared decision support program that teaches members how to collaborate with their provider to make more informed, less risky care choices—reducing demand for inappropriate surgeries and optimizing post-surgical outcomes.
