For benefits administrators and HR leaders at self-funded organizations, mid-year is a critical checkpoint. It is the moment to step back, review claims data, and ask an important question: is our surgical spend on track with our budget, or are we headed for a challenging renewal conversation?
Surgical claims are among the most expensive and most variable line items in any self-funded health plan. A handful of high-cost procedures at high-cost facilities can significantly shift a plan’s financial trajectory in a single quarter. The good news is that mid-year is also the ideal time to implement strategies that can bend the cost curve for the remainder of the plan year.
Reviewing Your First-Half Claims Data
Start by examining your plan’s surgical claims from the first half of the year. Identify the following:
- Total surgical spend to date: How does this compare to budget? Are you tracking above, below, or in line with projections?
- High-cost claims: Which individual procedures generated the largest claims? Were they performed at hospitals or ambulatory surgery centers?
- Facility mix: What percentage of surgical claims were processed through high-cost hospital systems versus lower-cost alternatives?
- Member utilization: Are employees aware of lower-cost options? Have any members taken advantage of zero-tier pricing at WellBridge Surgical?
The Impact of Facility Choice on Plan Performance
The facility where a surgical procedure is performed has an outsized impact on cost. Indiana’s hospitals charge, on average, nearly three times Medicare rates for commercial patients. An ambulatory surgery center like WellBridge Surgical performs the same outpatient procedures at 30 to 60 percent less.
For a self-funded plan, steering even a modest percentage of surgical volume from hospitals to an ASC can produce meaningful savings. Consider the math: if your plan processes 50 outpatient surgical claims in a year and each claim is $5,000 less at an ASC than at a hospital, that is $250,000 in annual savings, savings that directly improve the plan’s funded status.
Mid-Year Strategies to Reduce Surgical Spend
- Implement or Promote Zero-Tier Pricing: If your plan already includes a zero-tier arrangement with WellBridge Surgical, make sure employees know about it. If you do not yet have such an arrangement, mid-year is the right time to establish one. Waiving employee deductibles for procedures at WellBridge creates a powerful incentive for members to choose the lower-cost, higher-value option.
- Communicate with Your Workforce: Many employees are unaware that they have a choice in where their surgery is performed, or that choosing a different facility can save them thousands of dollars. A targeted mid-year communication highlighting WellBridge as an in-network option with transparent pricing can drive meaningful behavioral change.
- Engage Your Benefits Advisor: Work with your broker or consultant to analyze your first-half claims data and model the savings potential of directing more surgical volume to WellBridge. The data often speaks for itself.
- Review Pending Authorizations: For any surgical procedures that have been authorized but not yet scheduled, proactively reach out to the member to discuss lower-cost facility options. A single conversation can redirect a claim from a $20,000 hospital bill to a $8,000 ASC bill.
Planning for a Stronger Second Half
The decisions you make at mid-year can define your plan’s financial outcome for the entire year. By proactively managing surgical spend and directing volume to high-value facilities like WellBridge Surgical, self-funded employers can protect their plans, support their employees, and demonstrate that quality care and cost efficiency are not mutually exclusive.
WellBridge Surgical partners with approximately 90 self-funded employers across Indiana, covering more than 100,000 lives. Our team works with benefits leaders to analyze claims, model savings, and implement strategies that deliver results.
Healthcare can often feel intimidating and confusing concerning both pricing and treatment options. WellBridge Surgical remains committed to providing high-quality surgical services directly to patients with cost certainty, providing the peace of mind to proactively deal with preventative and corrective healthcare issues.
Visit our website at www.wellbridgesurgical.com to learn more about procedures and pricing, or call us at 317.480.4200.