Elective Surgery Highest in December... Why?

This video provides an in-depth exploration of the seasonal phenomenon of elective surgeries, specifically highlighting a significant surge in December. Dr. Eric Bricker, drawing from his experience as a hospitalist, initially observed this counterintuitive trend—hospitals being exceptionally busy during the holidays, particularly the week between Christmas and New Year's. He then delves into the underlying reasons for this national pattern and discusses its profound implications for healthcare finance and patient outcomes. The presentation emphasizes that the timing of these medical procedures is often driven by financial and work-related factors rather than purely clinical necessity.

Dr. Bricker explains that the 9% to 20% increase in elective surgeries during December is primarily attributed to two key factors. First, patients with commercial insurance plans have typically met their annual deductibles and out-of-pocket maximums by the end of the year, making the financial burden of a procedure significantly lower. Second, the holiday season offers an opportune time for recovery, allowing individuals to undergo surgery without having to take additional time off work. This non-clinical timing, driven by economic incentives and convenience, is a central theme, illustrating how external factors heavily influence healthcare utilization.

The video then progresses to detail the practical implications of this seasonality. For self-funded health plans, this December surge in outpatient procedural costs presents a budgeting challenge, as claims are often not filed, processed, and adjudicated until January or February, leading to a delayed understanding of actual year-end spend. Dr. Bricker provides a concrete example: a 1,000-employee company with a $10 million health plan, where a 20% surge in outpatient spend during December could result in an unexpected $50,000 expense. Beyond the financial aspect, the video critically examines the quality implications, introducing the "weekend effect." Studies show that elective surgeries performed later in the week (Thursday or Friday) have worse outcomes, including higher mortality rates, due to reduced hospital staffing. Dr. Bricker posits that the holiday period, particularly the week between Christmas and New Year's, often mirrors a prolonged "weekend" in terms of staffing levels, potentially exposing patients to similar increased risks of complications or adverse outcomes. He concludes with a personal recommendation against scheduling surgery during this high-risk period.

Key Takeaways:

• Elective Surgery Seasonality: There is a significant and consistent national phenomenon of increased elective surgeries in December, with reported increases ranging from 9% to as high as 20% compared to other months.
• Financial Drivers for Patients: The primary reason for this December surge is that many patients have met their health insurance deductibles and out-of-pocket maximums by year-end, reducing their personal cost burden for procedures.
• Work-Related Convenience: Patients also schedule surgeries in December to utilize holiday time for recovery, avoiding the need to take additional days off from work.
• Non-Clinical Timing: The timing of many elective surgeries is not clinically driven but is instead heavily influenced by financial incentives and work-life considerations, highlighting a critical aspect of healthcare utilization.
• Budgeting Challenges for Self-Funded Plans: Employers with self-funded health plans face budgeting complexities due to this seasonality, as the surge in December outpatient costs may not be reflected in claims data until January or February of the following year.
• Quantifiable Financial Impact: For a 1,000-employee company with a $10 million health plan, a 20% surge in December outpatient spend (which typically accounts for 40% of medical spend) could lead to an unexpected $50,000 expense.
• The "Weekend Effect" on Outcomes: Research indicates that elective surgeries performed later in the week (Thursday and Friday) are associated with worse patient outcomes, including higher mortality rates, due to reduced hospital staffing.
• Holiday Staffing Risks: The period between Christmas and New Year's often experiences hospital staffing levels akin to a prolonged weekend, potentially extending the "weekend effect" and increasing the risk of complications for patients undergoing elective procedures.
• Relative vs. Absolute Risk: While the relative increase in mortality for surgeries later in the week is significant (e.g., 12% higher on Thursday, 24% higher on Friday compared to Monday-Wednesday), the absolute mortality rate for elective surgery remains low (less than 1%), meaning the increased risk is still small in absolute terms.
• Personal Recommendation: Dr. Bricker personally advises against scheduling elective surgery late in December, and would not recommend it for family members, due to the potential for worse outcomes linked to staffing levels.
• Employer/Payer Implications: The video suggests that employers and health plan administrators need to be aware of this phenomenon and consider strategies to address its financial and quality implications, although specific solutions are beyond the scope of this particular discussion.

Key Concepts:

• Elective Surgery: A medical procedure that is scheduled in advance because it is not an emergency, allowing time for patient choice and preparation (e.g., joint replacements, endoscopies, sinus surgery, carpal tunnel release).
• Deductible: The amount of money an individual must pay for healthcare services before their insurance plan starts to pay.
• Out-of-Pocket Maximum (OOP Max): The most an individual has to pay for covered services in a plan year. After reaching this limit, the insurance company pays 100% of the costs for covered benefits.
• Self-Funded Plan: A type of health insurance plan where an employer directly pays for employees' healthcare costs rather than paying premiums to an insurance carrier.
• Weekend Effect: A phenomenon observed in healthcare where patient outcomes for certain procedures or conditions are worse when treatment occurs on weekends, often attributed to reduced staffing levels or access to specialized services.

Examples/Case Studies:

• Types of Elective Surgeries: Hip and knee replacements, endoscopies (colonoscopies, upper endoscopies), sinus surgery, carpal tunnel release.
• Financial Model for a 1,000-Employee Company:
  • Total health plan spend: $10 million ($10,000 per employee per year).
  • Medical spend (80%): $8 million.
  • Outpatient procedures/services spend (40% of medical spend): $3.2 million.
  • Average monthly outpatient spend: $267,000.
  • Impact of a 20% December surge: An additional $50,000 in outpatient spend for that month.