Member-Focused Surgical Decision Support Linked to $5,154 in Annual Savings Per Participant, New Data Shows

Paradigm analysis of 50,000+ members found reductions in inappropriate surgeries, ER visits, and inpatient days

TAMPA, Fla.--(BUSINESS WIRE)--Today, Paradigm, a specialty care management organization focused on delivering value-based solutions to improve outcomes for patients, payers, and providers, released a report highlighting the financial and clinical results of its My Surgery program. The report examines how Paradigm’s digital shared decision support platform reduces total cost of care for health plans by reducing inappropriate utilization and improving outcomes for members considering preference-sensitive surgery.

Preference-sensitive surgeries — procedures with two or more non-surgical alternatives, where the most appropriate option is closely tied to a patient’s risk factors, clinical profile, and goals — account for an average of 30% of total health plan medical spend, although many are avoidable or inappropriate. The significant financial impact of these surgeries often remains hidden as they cut across member populations and specialties, and are rarely aggregated in plan financials. Despite the opportunity to better address this subset of elective procedures, many payers continue to prioritize downstream interventions that engage members only after they have already decided to undergo surgery.

An analysis of more than 50,000 members across Paradigm’s book of business found that My Surgery significantly reduced inappropriate surgeries and post-surgical complications, lowering total medical costs for health plans. The findings highlight the need for health plans to incorporate member-focused interventions that tackle this costly category of spend upstream rather than relying primarily on downstream tactics such as prior authorization, clinical reviews, and network management.

The findings are based on a difference-in-differences methodology — the industry standard for real-world programmatic outcomes evaluation and ROI validation — where My Surgery users were compared to a propensity-matched control group of non-participants. Preference-sensitive surgery outcomes and costs for both groups were tracked for six months before and after program completion to isolate statistically significant improvements directly attributable to the My Surgery program.

“For too long, the healthcare industry has approached surgical decision-making too late in the process, after patients have already committed to a procedure,” said John S. Watts, Jr., CEO of Paradigm. “This report demonstrates that earlier guidance can help members make more informed decisions about their care. When members understand their risk factors, treatment options, and how to prepare and recover from a procedure, they can more meaningfully collaborate with their providers to make appropriate care choices. By investing in upstream, member-focused shared decision-making programs, health plans have a meaningful opportunity to improve outcomes, reduce avoidable complications, and better manage cost of care.”

Key findings from the report include:

• My Surgery generates average 6.8:1 ROI and $5,154 in annual medical cost savings per participant for health plans: Of those savings, $1,868 per participant per year (36%) comes from surgery avoidance, while $3,286 per participant per year (64%) is driven by surgical outcomes optimization. Among Medicare populations, health plans save $5,764 per participant annually, while savings for commercial populations reach $4,356 per participant annually.
• My Surgery reduces inappropriate utilization, with 116 fewer surgeries per 1,000 program participants: The program helps members better understand their treatment options, surgical risks, and expected outcomes so they can make more informed decisions with their providers and avoid inappropriate procedures.
• My Surgery reduces post-surgical complications: When members choose to move forward with a preference-sensitive surgery, outcomes improve because My Surgery teaches them to prepare for their procedure and recovery. The program delivers 184 fewer ER visits, 884 fewer inpatient days, 82 fewer sepsis cases, and 23 fewer surgical complications per 1,000 participants.

“Health plans have spent years trying to control surgical utilization and costs,” said Nicola Merryman, SVP, Healthcare Solutions at Paradigm. “While the focus has traditionally been on downstream strategies, the reality is that there is a significant — and often overlooked — opportunity to impact utilization through upstream member decision-making support that helps them better understand their options and set realistic expectations before committing to a surgery. This level of education improves their health literacy and empowers them to utilize those skills in any care situation or setting.”

To learn more about how health plans can lower surgical spend while improving outcomes for members and to download the full report, please visit: https://www.paradigmcorp.com/healthcare/shared-decision-support/mysurgerydatareport-2026/.

About Paradigm

Paradigm is a specialty care management organization dedicated to delivering value-based solutions for over 35 years—driving the best possible outcomes for patients, payers, and providers. The company brings deep clinical expertise to enable successful recoveries for individuals facing the most challenging injuries and diagnoses, and it has supported more than one million members through an evidence-based digital solution that improves health literacy and enables a personalized care experience. The company consistently delivers proven cost savings for health plans, while improving outcomes across the continuum of care. For more information, please visit www.paradigmcorp.com/healthcare.