How technology can solve the pervasive problem of unnecessary surgery

For someone trying to choose a physician to perform a joint or hip replacement, bariatric surgery or spinal fusion, a natural question would be “How many procedures has this surgeon performed?” But a better question is: “How many procedures has this surgeon avoided?”

This is an important query because too often, Americans with chronic ailments receive unnecessary, invasive screenings and procedures that do little to help them while ratcheting up anxiety, pain, risks, and costs.

A main culprit behind this epidemic of overtreatment is the American fee-for-service healthcare system, which has long incentivized avoidable medical care. Physicians themselves acknowledge the problem, estimating that as much as 11.1% of all surgical interventions are given inappropriately. Another study found 24% of people in Medicare get unnecessary surgery, cancer or cardiac screening, or diagnostic testing at a cost of $1.8 billion annually, according to a study in JAMA Internal Medicine.

The evidence is clear: In this broken system, employers overpay for surgeries that their patients don’t always need—and that sometimes causes more harm than good. In fact, surgical admissions account for approximately half of inpatient spending, and surgical spending had the largest cumulative growth of any expense category between 2014 and 2018, rising 11% over the period, according to the Health Care Cost Institute.

Want to dive deeper into the impact of unnecessary care? Download Carrum’s eBook The Economics of Surgery Avoidance.

Value-based COEs: A compelling solution

As companies grapple with this unsustainable system, Centers of Excellence (COE) provide a compelling solution. By adopting plans that offer COEs, employers can create a network of top-performing doctors who deliver reliable outcomes for fixed prices. The appeal of predictable outcomes and costs is so great that four-fifths of employers already offer at least one condition-specific COE.

However, even this solution remains chained to the flawed fee-for-service model. This is because most COEs operate through carrier-based contracts that still reimburse for each individual procedure—even when that procedure doesn’t help a patient.

To fix this problem through a value-based approach, Carrum Health has spent nearly a decade refining proprietary methods to analyze provider quality and realign incentives to avoid unnecessary surgeries, while making the necessary interventions more affordable. Its plug-and-play technology platform offers data science and machine learning components that complement a 50-point personal evaluation process to gauge doctors’ commitment to appropriate care while monitoring overall cost and patient outcomes.

Using data to avoid overtreatment

Creating a value-based COE that paints a broader, more accurate picture of a surgeon’s performance is far more complex than building a traditional COE. This is because, while traditional COEs can analyze readily available readmission rates to determine the best-scoring doctors, no singular piece of hospital-reported data can determine whether a surgery was the most appropriate treatment.

To create a more nuanced and accurate view of physician performance, Carrum uses a proprietary algorithm that dives deep into practice patterns. Carrum’s analysis evaluates a unique set of variables for all potential network partners, including billing activity, patient demographics, referral patterns, and more.

After Carrum’s algorithm flags promising provider partners, a team meets with those surgeons individually to dig even deeper into their approach. Through this vetting process, only the very best physicians—the top decile—are invited to join the platform. They provide common, costly procedures such as joint replacement and spinal and bariatric surgery for a single, transparent, bundled cost. This approach improves health outcomes for patients and can reduce employers’ contributions to employee healthcare by more than 45%, according to a recent RAND report.

To explore how advanced analytics help Carrum identify the best surgeons who operate only when necessary, download The Economics of Surgery Avoidance.

Embedding a cautious approach

In a fee-for-service environment, patients will always face the risk of being steered toward needless tests and procedures. Beyond wasting between $76 billion and $101 billion in the U.S. annually, according to JAMA, this overtreatment also results in mistakes and injuries that cause 30,000 deaths in the U.S. each year.

The bottom line: Even in an era of unprecedented medical advancement, surgery remains risky. Any surgical case comes with a host of potential complications and unknowns. And invasive procedures are not guaranteed to solve a patient’s problem. Accordingly, most patients benefit from beginning with the least invasive treatments, such as physical therapy, lifestyle changes, and acupuncture, before advancing to surgical consideration.

Carrum’s potent combination of machine learning and intensive personal interviews allows it to effectively identify the best surgeons who thoughtfully evaluate each patient to determine the most appropriate treatment. By leveraging its network, you can direct your employees to doctors who, first and foremost, do no harm.

To learn more about value-based COEs and how they work, download Carrum’s eBook The Economics of Surgery Avoidance.