It’s open enrollment season. HR teams are fielding questions about deductibles, comparing plan tiers and reminding employees to make their elections before the deadline. Most of that attention goes to premiums and paycheck deductions.
Surgical care rarely gets the same scrutiny. It tends to come up only after a large claim arrives, an employee puts off a needed procedure, or the renewal shows the impact. Yet surgery is one of the most expensive and least predictable items in an employer’s health spend.
If your benefits strategy for the coming plan year doesn’t include a clear, affordable path to surgery, open enrollment is a good time to ask why.
The numbers employers are carrying into the new plan year
The KFF 2025 Employer Health Benefits Survey shows how much pressure employers and employees are already under:
- The average annual premium for employer-sponsored family coverage reached $26,993, up 6% from 2024.
- Workers contributed an average of $6,850 toward that family premium.
- The average single-coverage deductible was $1,886, and 34% of covered workers had a single deductible of $2,000 or more.
- One-third of covered workers were enrolled in a high-deductible plan with a savings option.
Employers pay more every year, and employees pay more before their coverage starts. When an employee needs surgery, both sides feel it.
A benefit on paper isn’t a benefit in practice
Offering a benefit doesn’t mean employees use it well. Castlight Health’s 2026 Employer Health Benefits Experience Survey of 2,000 workers, reported by WorldatWork, found that a third of workers bypass their employer benefits entirely and build their own do-it-yourself workarounds. It also found that 29% spend more than $500 a year out of pocket on items their employer likely already covers.
With surgery, that gap tends to show up in a few ways:
- Employees delay a needed procedure because they’re worried about the deductible, and the condition gets worse and more expensive.
- Employees go to the default hospital option because nobody showed them an alternative, and the plan pays inflated facility rates.
- Employees get separate bills from the surgeon, anesthesiologist and facility, and the confusion turns into frustration with the benefits package and the employer.
We call this the utilization gap: the distance between the coverage employers pay for and the care employees actually get, at a price that makes sense.
Why surgery is where the gap costs the most
Surgical claims are high-dollar and hard to predict. One procedure billed at traditional hospital rates can change a self-funded employer’s year, push toward stop-loss thresholds and show up again at renewal. Prior authorizations and scheduling delays also keep employees out of work longer than necessary.
That makes surgery one of the clearest opportunities to lower cost and improve the employee experience together.
What a working surgical benefit looks like
Smith Medical Direct Specialty Care in Littleton offers a direct-pay surgical model built for self-funded employers and cost-conscious benefit strategies:
- One bundled, all-inclusive price. Surgeon fees, anesthesia, facility fees, and standard labs and supplies are included up front. There are no separate bills.
- Typically 40–60% less than traditional hospital billing.
- Predictable costs. Bundled pricing reduces claim volatility and large-claim surprises that affect stop-loss and renewal rates.
- Faster access. No prior authorizations means employees get care sooner and return to work sooner.
- Board-certified surgeons. Employers don’t have to give up quality to save money.
- Works with your existing strategy. Smith’s transparent pricing fits self-funded plans, high-deductible plans, cost-sharing programs and innovative benefit platforms.
“Employers don’t need another benefit their people don’t use. They need a surgical option that’s simple enough to explain at open enrollment and affordable enough that employees actually choose it.”
— Lisa Fagan, CEO, Smith Medical Direct Specialty Care
Five questions to ask during open enrollment
Whether you manage benefits in-house or work with a broker, these questions show whether your surgical benefit is doing its job:
- Could an employee find out what a common procedure, such as a knee arthroscopy or carpal tunnel release, would cost them before scheduling it?
- Does your plan include a bundled or direct-contract surgical option, or does every procedure default to hospital billing?
- If you have a lower-cost option, is it explained in your open enrollment materials, or does it only come up after an employee asks?
- How many large surgical claims did your plan absorb last year, and what did they do to your renewal?
- Has your benefit advisor brought you transparent-pricing alternatives for surgical care?
If you answered “no” or “I’m not sure” to two or more of these, there’s probably room to improve.
Close the gap before the next claim arrives
Open enrollment is the one time of year employees pay close attention to their benefits. It’s also a good time for employers and benefit advisors to make sure the surgical benefit holds up, so employees have a clear, affordable option when they need a procedure.
Smith Medical works directly with self-funded employers and benefit advisors to build transparent surgical pricing into their benefit strategy.
Call the Benefits Advisor Hotline at 720-912-8289 or contact our employer team to see what bundled surgical pricing could save your organization or your clients.
Our prices are all-inclusive. Learn more at smithdsc.com/pricing-disclaimer.
