The Utilization Roadmap for Success

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Imagine if the healthcare journey was simplified with just three simple steps to secure quality care that delivers value and ROI. Fortunately, this can be a reality for self-funded employers — but only with comprehensive support to utilize the solution.

Often equated to denied coverage and limited spending causing frustration and compromised care, utilization management is actually the one key metric companies can use to measure and demonstrate their self-funded healthcare plan’s effectiveness, according to John Zutter, CEO of Employer Direct Healthcare (EDH).

“Utilization is also the single biggest hurdle that almost every digital health solution faces,” states Zutter. “No matter what, the self-funded plan will not deliver value to employers if members do not use it.”

A clear utilization strategy is central to the success of our SurgeryPlus solution. Created to dramatically lower costs, improve outcomes and transparency across over 1,500 plannable surgical procedures, SurgeryPlus exists to build an ecosystem of quality care and savings for employers and their employees.

Find out the three steps to successful utilization our partners embrace for quality care, network access and fair pricing.

Key #1: Right care

With healthcare spending expected to grow at an average of 5.5% a year between 2020 and 2027, the importance of providing care centered on evidence-based clinical guidelines has never been more important. A key part of savings and quality outcomes, a thorough prior authorization process ensures a test, treatment or procedure ordered by a healthcare provider is safe and appropriate. But this can only happen when the point of care starts with the highest quality medical care.

Employer Direct Healthcare’s SurgeryPlus solution empowers premium medical care through the nation’s largest Centers of Excellence (COE) network. By offering over 400 hospitals and ambulatory surgery centers along with thousands of high-quality and carefully selected surgeons, SurgeryPlus members are ensured better information and advice to guide members to the best health outcomes. Through utilization management, we steer care toward clinically recommended next steps — and helps self-insured employer avoid the costs of low-value tests or procedures. With more than 1,500 commonly covered surgical procedures in addition to personalized Care Advocate guidance, members are provided step-by-step assistance throughout their healthcare journey for the best overall solution.

Case in point: In over 20% of joint replacement consultations where a SurgeryPlus member has already received a surgical diagnosis, SurgeryPlus physicians recommend either non-surgical or less-invasive solutions. In turn, employers realize on average over $115 in savings per employee per year on surgical spend on plannable procedures; the complication and readmission rate is under 1%.

Key #2: Right time

Understanding the why and when of a surgical procedure is essential for the best outcomes, both medically and financially. But just knowing surgery is needed can be confusing and intimidating.

Is the surgery elective; or is it an urgent medical need? Will it be performed inpatient requiring an overnight hospital stay, or can the procedure be performed as outpatient or same-day surgery? And what type of pre-surgery tests are actually necessary?

To help navigate the myriad of surgical questions, our specially trained Care Advocates personally handle every member interaction to ensure appropriateness of care and patient safety. This personalized support and guidance is based on providing a holistic, trusted experience that manages the overall surgical experience.

Clear, effective and consistent communication tools are also offered to our clients. Based on a multi-channel approach to drive awareness, understanding and utilization, self-funded employers are provided a wide variety of tools to ensure their members know how and when to call SurgeryPlus. From mailers, new hire orientation and a benefits portal, to webinars and intranet assets, clients have access to tools that help drive utilization of the SurgeryPlus benefit.

Key #3: Right place

Finding the best surgical care is far from simple. With an ever-crowded ecosystem offering so many digital health solutions to plan sponsors, it can be challenging to find smart solutions that aren’t confusing for members.

“Simplicity is not only about trying to implement a strategy that provides a meaningful experience, the solution must be easy for the member to understand, use and access,” explains Bryan Magstadt, Senior Vice President of Business Development at EDH. “It must also plug into other solutions to create the seamless path of care for the member.”

While carrier COE models can provide direction to a specific facility, they cannot guide care to a specific particular surgeon; instead they require a referral from a primary care doctor to see a specialist. There’s no doubt the facility is important, but often it’s the surgeon that drives better outcomes for members. By combining high-quality facilities paired with high-quality surgeons, SurgeryPlus complication rates are well below industry averages.

To address quality care limitations in rural areas, the SurgeryPlus network is designed to be regionally accessible. If a member cannot get care locally, we find the best options within a reasonable car ride — often times just under 65 miles. In addition, coverage for any related travel expenses eliminates barriers for members to get COE surgical care.

“We’re focused on simplifying the self-funded solution for a plan sponsor through multiple solutions in a manner that is easy to implement and administer,” Magstadt states. “It’s our on-going goal to simplify the complex experience of navigating healthcare, benefits and surgery by providing direction to the right place for care.”

About Employer Direct Healthcare and SurgeryPlus®
Employer Direct Healthcare is a market-leading healthcare services business providing high-quality and cost-efficient solutions for self-funded employers and their members. The company’s solutions democratize healthcare for its members, facilitating access to top-quality care at fair prices nationwide.

Employer Direct Healthcare’s first product, SurgeryPlus®, is the market-leading surgical benefit, providing full-service concierge and network services to millions of covered members across hundreds of employers. In 2022, the company will launch a first of its kind, comprehensive end-to-end oncology solution. For more information and the latest updates about Employer Direct Healthcare, visit and follow us on LinkedIn.

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