7 Ways Employers Can Evaluate Surgical Quality 

Finding a high-quality surgeon isn’t as simple as choosing someone “in network.” The surgeon, the procedure and the facility all influence the outcome. Yet employers still rely on quality measures that capture only a small part of the picture.

The most effective employer surgical cost management strategies go much deeper. They evaluate whether surgery is appropriate in the first place, identify the right surgeon for the specific procedure and continuously monitor quality over time.

At Lantern, quality is the north star guiding everything we do. Look for these seven qualities when evaluation a surgical solution.

1. Review the Surgical Outcomes to Evaluate Quality

Clinical outcomes are often the first place employers look when evaluating surgical quality, and for good reason. Readmission rates, complication rates and surgical site infections all provide valuable insight into how consistently surgeons deliver safe, successful care.

Together, these metrics can help identify surgeons who consistently achieve better outcomes and avoid unnecessary complications.

“You want to be sure that the Center of Excellence is providing your employees the right procedure at the right place with the best surgeon for that surgery,” says Jason Tibbels, MD, Chief Medical Officer at Lantern.

Across Lantern’s book of business, fewer than 1% of surgical cases experience complications. This number is especially significant considering one study found  38% of patients admitted to the hospital for surgery experienced an adverse event, with 15.9 experiencing major adverse events. The same study found that 59.5% of adverse events are potentially preventable, while 20.7% of adverse events are definitely or probably preventable.

While outcomes are an essential starting point, they represent only one piece of the surgical quality evaluation. “It’s not enough to have just good outcomes,” says Dr. Tibbels.

2. Determine if Providers have Procedure-Specific Expertise

Effective surgeon selection strategies begin with recognizing that surgical expertise is highly specific. The skills, experience and outcomes that make a provider outstanding for one procedure don’t automatically translate to another, even with the same specialty.

“It’s been proven over and over again that the surgeons who do the most volume in a specialty tend to get the best results,” says Steve Lucey, MD, Orthopaedic Surgeon at EmergeOrtho. “It’s no different than if you go to your mechanic and you have someone that specializes in working on carburetors or mufflers, they’re going to be the best, the fastest and probably even the least expensive in town. That holds true in medicine.”

At Lantern, surgeons are evaluated at the individual CPT code for specific procedures. A surgeon who specializes in hip replacement may deliver exceptional outcomes for hips, but that doesn’t mean they’re qualified for shoulder surgery. The same principle applies across orthopedic, cardiovascular, bariatric and other surgical specialties.

“We now have a couple of decades of research very clearly demonstrating that high-volume surgeons, meaning high volume for a specific procedure, have better outcomes, including lower complication rate across most surgical categories,” Dr. Tibbels says.

3. Ensure Appropriateness of Care by Reviewing Surgical Avoidance Rates

Sometimes, the best option is no surgery at all. Evaluating whether surgery is clinically appropriate is one of the most overlooked aspects of surgical quality evaluation. Employers should look for Centers of Excellence or Networks of Excellence that provide independent second-opinion reviews as part of the care journey, along with the highest-quality doctors in the network who recognize that surgery first isn’t always the best route of care.

“A surgeon can be the very best technician on the planet with the lowest complication rate, no infections and no readmissions,” Dr. Tibbels says. “But if they’re operating on people that would be better off without surgery or would be better off with a less-invasive or more-conservative treatment, that’s poor quality. We’re very diligent about evaluating providers for appropriateness.”

In many cases, physical therapy and less-invasive treatments prove more effective and appropriate, than surgery. Helping employees avoid unnecessary procedures is one of the most effective strategies for MSK surgery cost reduction while improving patient outcomes.

4. Ask if there’s Independent Review and Oversight When Evaluating Quality

One of healthcare’s biggest misconceptions is that a single score or ranking can evaluate surgical quality. It can’t. Employers should look beyond rankings and understand how providers are evaluated.

“There’s no single claims-based solution that can give you red, yellow, green, or one number score to paint the whole picture of quality,” Dr. Tibbels says. “When someone says quality is in the top 10%, you should say, ‘Of what? As measured how and by whom?’”

At Lantern, quality assessment combines multiple layers of review, including fellowship training requirements, qualification for specific procedures, detailed case log reviews and independent appropriateness reviews through Global Appropriateness Measures (GAM).

Independent oversight evaluates surgical quality through a comprehensive, evidence-based process rather than relying on a single metric.

5. Find Out if the Center of Excellence Performs Continuous Quality Monitoring

Ensuring surgical quality requires ongoing evaluation. The best programs continuously monitor providers, reviewing new clinical data, disciplinary findings and performance trends to ensure surgeons consistently meet high standards.

“Any good quality program is iterative,” Dr. Tibbels says. “Every year, we’ll reanalyze from a data standpoint. For example, someone may have a new board sanction or some sort of reprimand, so we’re monitoring those things in real time. And then every year we’ll relook at the data to see if we need to flag someone for a full review.”

6. Look at Care Site Selection

Beyond surgical quality evaluations, employers should also evaluate where surgery takes place.

Many procedures can be safely performed—and at a lower cost—in multiple settings, including hospital outpatient departments and ambulatory surgical centers. Selecting the right setting can improve the patient experience, while helping employers avoid unnecessary healthcare spending.

Rather than steering every patient to the same type of facility, employers should look for solutions that evaluate the surgeon, the procedure and the site of care together. That ensures employees receive high-quality care in the most appropriate setting for their clinical needs.

7. Understand How a Specialty Care COE Measures Patient Satisfaction

Quality extends beyond avoiding complications. Traditional quality metrics tell only part of the story because most surgeries don’t result in major complications. Employers should also evaluate whether patients regained function, improved their mental well-being and returned to the activities that matter most, whether that’s playing with grandchildren, returning to work or living without chronic pain.

Patient-reported outcomes measure whether surgery truly improved a person’s life. Especially in orthopedics, these validated self-assessments allow patients to report factors like pain relief, mobility, physical function and overall quality of life.

“There’s really good evidence that a patient’s perception of their experience and how they evaluate that, meaning, ‘Was my surgeon professional? Did they listen to me? Did they understand my needs? Did they spend time with me?’ Dr. Tibbels says. “All of these things actually translate into clinical outcomes. When patients rate their experience higher, they actually have better functional status, they have less complications and lower mortality.”Lantern’s independently operated Patient Safety Organization (PSO) identifies safety issues, analyzes trends and drives continuous improvements in patient care through honest, unbiased reporting.

Seeing the Complete Picture of Surgical Quality

Employers shouldn’t have to accept a “trust us” approach to surgical quality. Prior authorization alone doesn’t ensure employees receive quality care from the right surgeon at the right facility. In fact, prior authorization has been linked to delayed care and adverse patient outcomes.

No single metric can determine surgical quality. Employers need a comprehensive approach to evaluate clinical outcomes, procedure-specific expertise, appropriateness of care, independent oversight, monitoring and transparency, and patient satisfaction.

For employers and unions, having a trusted partner evaluate these quality indicators removes the guesswork of finding a top-quality surgical solution.

“Knowing there’s this long list of indicators, quality indicators that Lantern vets out on behalf of an employee health plan really helps the decision for us to  be much more comfortable with sending participants to Lantern,” says Kim Baker, Senior Advisor, Health and Welfare Benefits at an energy manufacturer with 11K eligible employees.