Surgery is one of the biggest decisions a person can face in healthcare.
For employees, it can be stressful, disruptive, and hard to navigate. For employers, it is one of the areas where costs can run high, quality can vary widely, and the experience can break down fast.
That is why employers should expect more from surgery centers of excellence (COE) programs.
For a long time, the promise has been straightforward: help people get to high-quality providers, improve outcomes, and reduce costs. That still matters. But it is no longer enough.
Healthcare is more expensive. Employees expect a better experience. And employers need to know that the programs they are paying for are actually helping people get the right care, not just sending them to a narrower list of providers.
The real questions to consider are: Is your COE helping people make better decisions, or is it just steering them toward surgery? Is your COE truly delivering the savings it claims to achieve?
The best surgery COE programs do not start with the procedure. They start earlier. They help people understand their options, get to the right specialist, and make better informed decisions. They make care easier to access and easier to navigate. And sometimes the best outcome is to avoid surgery altogether.
Here is what employers should be paying attention to.
1. Does the program help people avoid unnecessary surgery?
This is the part that not every vendor wants to emphasize: sometimes the best surgical outcome is no surgery at all.
A strong COE program should not be built to move people efficiently into the operating room. It should be built to help them get the right care.
Nobody wants surgery they do not need. No one wants anesthesia, recovery, time away from work, or the risk that something goes wrong. And that risk is not theoretical. Unnecessary surgery remains a real issue across the system. In some controversial procedures, published research has found unnecessary surgery rates as high as 30%. In spine care, expert reviews have found that more than half of patients referred for surgery did not actually need it. And when the wrong procedure happens, the consequences can follow patients for years.
That is why employers should ask a basic question: is this program designed to confirm the right decision, or simply accelerate it?
The old saying is measure twice, cut once. That logic applies here, too. Before surgery, people should have access to conservative care, expert review, and support that helps them understand whether a procedure is truly necessary. Sometimes the right next step is physical therapy. Sometimes it is virtual musculoskeletal support. Sometimes it is surgery. What matters is that the decision reflects what is best for the person, not what best fits the business model.
2. How are savings actually being measured?
Every COE vendor has a ROI story. Employers should look closely at how that story is built.
In some cases, the vendor sets the benchmark, defines the methodology, and reports the result. When that happens, the savings figure may be less an objective outcome than a constructed one.
Benchmarks based on national averages, list prices, or inflated comparators can make performance look strong without reducing actual employer spend. A program can generate meaningful savings simply because the math was designed to show it.
That is why employers should ask: savings compared to what?
A credible benchmark should reflect the employer’s own population and claims experience whenever possible. If that is not available, the methodology should at least rely on an independent, transparent reference point that can be explained and scrutinized.
Savings matter. But if the number cannot be clearly explained, it should not be blindly trusted.
3. How does the COE vendor make money?
One of the simplest lessons in healthcare is that incentives drive behavior.
Employers should understand exactly how a COE program makes money and who benefits from its decisions. Are vendors paid based on referral volume? Do provider relationships shape recommendations? Are there financial arrangements behind the scenes that create conflicts employers may not see right away?
These are not side questions. They go directly to whether the program is acting in the best interest of the employer and the employee.
The strongest models align everyone around the same goal: better outcomes, better experience, and lower total cost of care. When incentives are misaligned, problems usually show up somewhere — in the recommendation, in the routing, or in the results.
For employers operating under ERISA, that is not just a contracting issue. It can also be a fiduciary issue.
4. Can you see the total cost of care before the procedure happens?
Many employers assume that when surgery is routed through a COE, the cost is predictable. That is not always true.
Anyone who has dealt with surgery knows how quickly the billing can splinter. The surgeon bills separately. So does the facility. Then comes anesthesia, radiology, implants, recovery, and follow-up care. What looks like one episode on the front end can turn into a confusing series of charges on the back end.
That is not good for the employer, and it is certainly not good for the patient.
The best programs create clarity up front. They define the full episode of care before the procedure, including what is covered and what financial responsibility to expect. That kind of transparency makes it easier to plan, easier to compare options, and easier to trust the process.
5. Are you measuring what really matters?
If the only metric a COE program can point to is savings, it is leaving too much out.
Employers should also care about clinical outcomes, complications, readmissions, recovery, return to work, and the employee experience. Did the person get the right treatment? Did they recover well? Did the program make a difficult moment easier to navigate? Would they make the same choice again?
Those are the measures that tell you whether the program is actually working.
The goal is not just cheaper care. It is better care.
The bottom line
Employers do not need another vendor that promises savings and delivers a referral pipeline.
They need partners who help people make better decisions. Partners that make care easier to access, easier to understand, and easier to trust. Partners that bring real clarity to quality, incentives, and cost.
The best COE programs do not just steer people to surgery. They help prevent incorrect, delayed, and unnecessary care. And sometimes the most valuable thing they do is help someone avoid surgery altogether.
That is the standard employers should be demanding.